Do you support Optometrists doing surgery? - ODs allowed to do scalpel surgery in OK!

[Andrew_Doan]

Not an Opthalmologist or OD here.... but I do have some comments as a third party MD.

1) WTF is up with Oklahoma.. I mean seriously... let us be real for just 1 minute... Time out. If there is a lack of Ophthalmologists in Oklahoma why isnt the state constructing a serious residency over there?

There is a residency program in Oklahoma: http://www.dmei.org/

2) There is no avoiding it... make them a residency before they eat up more of your practice.

There is fear that this is where things may head in the future.

Thanks for the post!

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[Faebinder]

There is a residency program in Oklahoma: http://www.dmei.org/

But obviously not too many positions... I don't believe for a second that people would not come if more positions are opened. I realize it is not as simple as it sounds but this is in the hands of the ophthalmology community and they should care about the spread of their specialty... It is possible to sponser a couple of residency positions with the condition that the graduate practice in the state for 5 years minimum. I bet that after five years, the opthalmologist would not want to pack up and move.

My two cents...

 

[PBEA]

Not an Opthalmologist or OD here.... but I do have some comments as a third party MD.

1) WTF is up with Oklahoma.. I mean seriously... let us be real for just 1 minute... Time out. If there is a lack of Ophthalmologists in Oklahoma why isnt the state constructing a serious residency over there? Does anyone even dare to claim that if an Ophthalmology residency opened in OK that no MD/DOs wouldn't go there? They would be flooded! And all the published data shows that where you finish your residency is where you are likely to practice... they want more opthos then they need to open a residency over there... not go give ODs extra privilages with the excuse that no ophthos are around. You don't drop the qualifications, that's just stupid and ignorant...

2) My personal view is that OD should just stop this fight and just work on becoming a residency after medical school. You will start getting hospital privilages and you will get referals from other MD/DOs. Everyone would be happy.. the relationship between Optemitrists and Ophthalmologists would turn into that of Neurologists/Neurosurgeons or that of Cardiologists/Cardiovascular Surgeons. It would fix the problem entirely. The problem is that I bet OD higher ups would never even consider this and Ophthalmologists would are too scared because it might shrink their residencies like cardiovascular surgery shrunk after Cardiology became invasive. My advise to Ophthalmology... There is no avoiding it... make them a residency before they eat up more of your practice.

I realize comment number 2 will make people go wild... but whatever... It's an outside the box thought.

Wow, Im an OD and actually love you . Are you sure you are not mining my posts for GREAT ideas? The logic here is a bit harsh, but you have just echoed my own sentiments in nearly every aspect. Bottomline ophthalmology/optometry, merge the professions or continue waging constant, costly, stupid political innuendo and wasteful erosions to our practices. Too bad though, like AD states ophthalmology has its hands full trying to recover lost dollars from big insurance, fight the man AD, fight the man!

 

[acurarte]

There is a residency program in Oklahoma: http://www.dmei.org/



There is fear that this is where things may head in the future.

Thanks for the post!

As a side note, there is also a D.O. ophthalmology residency program in Tulsa with two residents per year and possibly soon to be 3 per year.

 

[Northerner]

This is just so sad.

 

[PBEA]

This is just so sad.

Maybe you could elaborate?

 

[4424]

last i checked oklahoma's ophtho program was a top program with some amazing surgical #s.

 

[Northerner]

Maybe you could elaborate?

It's sad to see the rights and responsibilities that define a physician slowly being handed over to non-physicians (non-MD/DO).

Optometrists want to become ophthalmologists. (the issue discussed here)

Podiatrists want to become orthopedic surgeons. (discussed ad nauseam in the Podiatry Student forum)

Two extremely competitive and important fields (two examples) that the majority of medical school graduates don't even have a shot to pursue, offering them to people without medical degrees is a little ridiculous.

 

[DiveMD]

It's sad to see the rights and responsibilities that define a physician slowly being handed over to non-physicians (non-MD/DO).

Optometrists want to become ophthalmologists. (the issue discussed here)

Podiatrists want to become orthopedic surgeons. (discussed ad nauseam in the Podiatry Student forum)

Two extremely competitive and important fields (two examples) that the majority of medical school graduates don't even have a shot to pursue, offering them to people without medical degrees is a little ridiculous.

Hear, Hear!

 

[DrMom]

As a side note, there is also a D.O. ophthalmology residency program in Tulsa with two residents per year and possibly soon to be 3 per year.

Actually, the DO residency only has one position per year.

 

[IlizaRob]

It's sad to see the rights and responsibilities that define a physician slowly being handed over to non-physicians (non-MD/DO).

Optometrists want to become ophthalmologists. (the issue discussed here)

Podiatrists want to become orthopedic surgeons. (discussed ad nauseam in the Podiatry Student forum)

Two extremely competitive and important fields (two examples) that the majority of medical school graduates don't even have a shot to pursue, offering them to people without medical degrees is a little ridiculous.

I often read posts from those who believe that any non-MD/DO profession should not progress in scope and training. I find it comical that those same people most likely do not understand the history behind medicine, or, they certainly dont post like they do. Not too long ago the AMA once said that the osteopathic profession was a cult and that they would never be considered main-stream medicine. Today, and rightfully so, they are considered equals. Why must the progression of medicine stop there? Im not saying that optometrists should do surgery. However, if they developed a multi-year residency and demonstrated competence in those techniques, I see no reason why they should not. Any advancement in education and training by any profession can only be a good thing. It seems to me that the resistence to scope exspansion of non-MD/DO professions is having less to due with quality of patient care, and more to due with politics and money, with a little ego mixed in.

 

[Northerner]

Any advancement in education and training by any profession can only be a good thing.

Sure, why not. Can only be a good thing. In fact, if it'll make you happy, let's offer surgery to anyone with any kind of health-related degree, as long as it seems like they can do it. Anyone with letters after your name, line up to the right and we'll check your ability to do surgery and thenceforth anyone with your letters will be able to do it forever. Why not? It's just drape this, cut that, cauterize this, watch out for that, sew a few layers and PRESTO, you're a surgeon!

The best part is, no one'll be able to argue against my "line up against the wall" system of practice rights distribution because they'll be effectively neutralized by accusations of being disrespectful of other health professions, elitism, naivete, and apparently insidious financial motivation.

It seems to me that the resistence to scope exspansion of non-MD/DO professions is having less to due with quality of patient care, and more to due with politics and money, with a little ego mixed in.

I could also very legitimately argue that scope expansion itself is having less to due with quality of patient care and more due to politics and money, with a little ego mixed in. If you think the pressure to increase scope of practice isn't politically and financially motivated, you've got another thing coming.

 

[IlizaRob]

Sure, why not. Can only be a good thing. In fact, if it'll make you happy, let's offer surgery to anyone with any kind of health-related degree, as long as it seems like they can do it. Anyone with letters after your name, line up to the right and we'll check your ability to do surgery and thenceforth anyone with your letters will be able to do it forever. Why not? It's just drape this, cut that, cauterize this, watch out for that, sew a few layers and PRESTO, you're a surgeon!

The best part is, no one'll be able to argue against my "line up against the wall" system of practice rights distribution because they'll be effectively neutralized by accusations of being disrespectful of other health professions, elitism, naivete, and apparently insidious financial motivation.



I could also very legitimately argue that scope expansion itself is having less to due with quality of patient care and more due to politics and money, with a little ego mixed in. If you think the pressure to increase scope of practice isn't politically and financially motivated, you've got another thing coming.

Im a little confused. Your first comments argued in favor of quality care. Then later you claim that politics and greed are the main factors of resitence. ??

 

[Northerner]

Im a little confused. Your first comments argued in favor of quality care. Then later you claim that politics and greed are the main factors of resitence. ??

You claimed that politics and greed are the main factors of resistance. I countered it by proposing that politics, money, and ego are the main factors of the expansion of scope, that which is being resisted. That's not to say you're wrong about the motivations for resistance (although largely opinion), but the pressure to allow cheaper, differentially educated, and more numerous practitioners more practice rights isn't necessarily because the care will be better.

 

[Mirror Form]

I often read posts from those who believe that any non-MD/DO profession should not progress in scope and training. I find it comical that those same people most likely do not understand the history behind medicine, or, they certainly dont post like they do. Not too long ago the AMA once said that the osteopathic profession was a cult and that they would never be considered main-stream medicine. Today, and rightfully so, they are considered equals. Why must the progression of medicine stop there?

Good question. It's a bad analogy for two reasons though.

For one thing, DO's have similar medical training to MD's. So it's a bad analogy b/c you're comparing apples and oranges. If optometrists started going to medical school first, and then optom school later, your analogy would be applicable.

Second, DO's became successful b/c allopathic schools have failed 100% in producing enough physicians. It seemed for awhile like 1/3 of our residency slots were going to people from foreign med schools. Meanwhile US citizens were being rejected from med school. Hence, the DO's provided something that was sorely needed (more med school grads). Whereas, THERE IS NO SHORTAGE OF EYE SURGEONS. Please read that last sentence over and over again. Hence, forming a new path toward eye surgery would not benefit patients in any way, shape, or form.

 

[PBEA]

Good question. It's a bad analogy for two reasons though.

For one thing, DO's have similar medical training to MD's. So it's a bad analogy b/c you're comparing apples and oranges. If optometrists started going to medical school first, and then optom school later, your analogy would be applicable.

Second, DO's became successful b/c allopathic schools have failed 100% in producing enough physicians. It seemed for awhile like 1/3 of our residency slots were going to people from foreign med schools. Meanwhile US citizens were being rejected from med school. Hence, the DO's provided something that was sorely needed (more med school grads). Whereas, THERE IS NO SHORTAGE OF EYE SURGEONS. Please read that last sentence over and over again. Hence, forming a new path toward eye surgery would not benefit patients in any way, shape, or form.

Sad but true, while planning surgical residencies post OD school might make sense, I see little reason to have highly invasive eye surgery being performed by more people. However, if there are truly some access issues (like in remote areas, etc) then the local government (or Federal govmnt) is WELL within its jurisdiction to try and provide for its citizens. One question is are there access issues that limited optometric procedures can capably deal with? That aside, the real mantra of optometry (IMHO) is to be allowed to deliver ALL primary eyecare in ALL jurisdictions.

 

[IlizaRob]

Good question. It's a bad analogy for two reasons though.

For one thing, DO's have similar medical training to MD's. So it's a bad analogy b/c you're comparing apples and oranges. If optometrists started going to medical school first, and then optom school later, your analogy would be applicable.

Second, DO's became successful b/c allopathic schools have failed 100% in producing enough physicians. It seemed for awhile like 1/3 of our residency slots were going to people from foreign med schools. Meanwhile US citizens were being rejected from med school. Hence, the DO's provided something that was sorely needed (more med school grads). Whereas, THERE IS NO SHORTAGE OF EYE SURGEONS. Please read that last sentence over and over again. Hence, forming a new path toward eye surgery would not benefit patients in any way, shape, or form.

You're right. I was only making the argument that if the optoms produced a training that was equal to med school. Osteopathic school is seperate from allopathic. Whats stopping other professions from doing the same in the future? Its just a thought. Not very realistic.

 

[Northerner]

You're right. I was only making the argument that if the optoms produced a training that was equal to med school. Osteopathic school is seperate from allopathic. Whats stopping other professions from doing the same in the future? Its just a thought. Not very realistic.

It is realistic. That's why everyone's up in arms about scope of practice. Once limited providers are expanding their education to try to make their training and education congruent to that of the current providers. After they do that, they can make the argument (and do) that "we have basically the same education an MD has!" While that isn't a bad thing per se, it's not the same education, the same selection process, the same rigors, the same grooming, the same standards, it's an education they feel is equivalent. There's a difference.

Whether or not that difference is significant we have yet to see. We're hesitant to invite change that looks like a (unproven either way) compromise of standards upon a proven effective system, because there's a lot to lose.

 

[MDB0073]

hello all,

I have read through this entire thread this evening and would like to voice my opinions/concerns. I am a first year medical student at a U.S. allopathic program (just so you know where I am coming from). I have noticed some people have mentioned letting O.D. schools set up their residencies so they can do surgical procedures. My response to this thought, if someone wants to be an eye surgeon then go to medical school and go through the same training that every ophthalmologist has had to go through. This idea of setting up O.D. residencies just complicates things in the M.D. realm pushing future medical students away from ophthalmology due to having the opportunity to take a less competitive route (through O.D. school) to becoming a eye surgeon (opthalmologist).

 

[qwopty99]

so MDB, how do u stop untrained MDs (gynecologists, urologists, etc - i'm not making this up) from doing refractions on the side at the local WM? it happens in Canada. (look up the term "refracting-MD")

 

[jefguth]

so MDB, how do u stop untrained MDs (gynecologists, urologists, etc - i'm not making this up) from doing refractions on the side at the local WM? it happens in Canada. (look up the term "refracting-MD")

Incredible, I never would have realized the phenomenon was so widespread that they even have a name for themselves.

For quite some time now I've been wondering how these non-ophthal MD's have been getting away with this when, at least in Ontario, each physcian has the following terms and conditions on his/her liscence: Dr. X may practise only in the areas of medicine in which Dr. X is educated and experienced.

But after googling "refracting-MD," I found this page, and then looked up the physicans registration with the college:

Current Referral Details:
Allegations of Dr. Franklin's professional misconduct and incompetence have
been referred to the Discipline Committee of the College. It is alleged that
Dr. Franklin failed to meet the standard of the profession and is incompetent
in his practice in performing eye examinations in the care of 28 patients.

 

[happy optho]

No No No, They Are Not Licensed Or Trained To Do So.this Should Not Be Even A Debatable Issue . Lets All Stick To What We Spent Our Long Hard Work And Training For .

 

[Meibomian SxN]

I've met many advanced knowledge ODs and have met some scary dumb MDs. Both exist. A doctor is as good as their training...

 

[Andrew_Doan]

I've met many advanced knowledge ODs and have met some scary dumb MDs. Both exist. A doctor is as good as their training...

That's the point. Optometrists are not trained in surgery but yet optometrists gain the ability to do surgery via politics.

 

[qwopty99]

so what's the current status quo in Oklahoma? according to these two editorials published in Archives in 2006,

Papalkar D, Francis IC.
The ophthalmologist or the optometrist as surgeon.
Arch Ophthalmol. 2006 Apr;124(4):604.

Hazel WA Jr.
Oklahoma's optometrists encroach on surgical rights of ophthalmologists; place politics above patient safety.
Arch Ophthalmol. 2005 Apr;123(4):559-60.

optometry got some limited scalpel surgery. i think i read somewhere here that this was (or is being) rolled-back. so where is it now?

 

[qwopty99]

so what's a fair resolution to this?

on one had, optometrists claim that doing medical/surgical procedures increases patient access to health care. the argument has usually been most successful when they claim there is poor patient access (for reasons including both financial and geographic) to ophthalmologic health care.

on the other hand, ophthalmologists argue it is not appropriate (or even ethical) for less trained (or in their view, untrained) non-surgical practitioners to perform potentially harmful invasive procedures.


do we want the best trained person to perform surgical procedures? i think most would agree, yes. however in many instances, if there wasn't access to a "second-tier" medical offering, many patients wouldn't have medical care at all. so on one hand, we're discussing the philosophy and ethics of providing only the "best" care, whilst on the other hand, we're talking about a practical reality of access to health care (or lack of).

another argument is whether optometrists would actually give "second-tier" medical care (ophthalmologists would say yes, optometrists would say no). it seems to me that integral to the optometric lobby is their claim that the level of care given is the same. of course, this is a major point of contention that many try to give an outright answer to (Yes vs No), whereas in many cases the answer is not so straightforward since it may depend crucially on what technique it is we're talking about -- i.e. are punctal plugs and epilations equivalent to injections and invasive surgery? probably not.

the key to a winning ophthalmologic lobby is to clearly demonstrate that the difference in training will lead to patient harm. the arguments cannot employ hyperbole - they have to be grounded in fact. the challenge, of course, is that optometrists have the financial argument on their side - they're willing to do these procedures which will reduce their cost and increase their access. money is always a significant consideration in governmental politics, which is why anything that can potentially reduce costs will always have someone in government willing to listen.

anyhoos - just a small editorial here.

 

[Eye Doc]

First off, I think it is a bit ridiculous for the Ophthalmology students/ Ophthalmologists to automatically think all Optometrists are out to get them. The majority of ODs do not even desire to perform surgical procedures. I think everyone should gain their own information and opinions of ODs instead of believing what they hear.

When have Ophthalmologists ever PROVEN that ODs have actually caused harm? Where is the evidence? Yes, there are more laws in Oklahoma that have expanded the scope of practice of the ODs. I think you should show us some kind of evidence that this NEW LAW of expanding our scope of practice has actually HARMED patients?

In Oklahoma, I know for a fact that MANY ODs and Ophthalmologists work together on a daily basis. What ever happened to caring about the patients? I think it is silly that some of you have made this into a power struggle to try and take the scope of practice away from ODs. When it comes down to it, it is all about dollars and cents, which is completely ridiculous.

What about the minor surgical procedures that PAs, dentists, and even Nurse Practitioners perform everyday? Why aren't there forums against these surgical procedures? They aren't Medical Doctors...and they are allowed to perform these minor surgical procedures.

What about the comment about how ODs alter their medical coding system to make more money by filing a procedure to insurance. This is something that is controlled by The American Medical Association. They have the authority to change these codes every year. So I am assuming if anyone has a problem with the way the ODs are coding their procedures, this would be something to take up with them.

Any complaint that is made toward a medical professional is required by law to be investigated. In the OD case, it is investigated by the Board of Examiners.

And no, Optometrists are not Med school hopefuls that just haven't made the grades. It is still a competitive field in Optometry. And mainly, we go into the field so we can help patients, end of story.

I am not out to tell Ophthalmologists that they are wrong, my goal is for them to know what is really going on. There is a lot of politics in the medical field. I think if we all put as much in our patient care as we do in our little power struggle, then our patients would fully benefit.

 

[toughlife]

The arguments used by ODs is the same CRNAs are using against anesthesiologists. Once the flood gates are open, there's no stopping. they will continue to push until they are seen as equal in the eyes of the law.

 

[Andrew_Doan]

The arguments used by ODs is the same CRNAs are using against anesthesiologists. Once the flood gates are open, there's no stopping. they will continue to push until they are seen as equal in the eyes of the law.

You are correct. Optometrists are now taking it to the federal level to include the word "surgery" in their scope of practice. This is similar to methods used in the past to introduce new scope. While ODs will not be doing cataract surgery by the end of the decade, this slow movement towards changing legislation sets up the stage for optometric surgery in the future.

Included below is a new bill being considered at the FEDERAL LEVEL. Usually, scope of practice issues are dealt with at the state level. Here are some facts about this bill and the Amercian Academy of Ophthalmology's opinion.

Facts about this bill:

American Academy of Ophthalmology Strongly Opposes the Optometric Equity in Medicaid Act of 2007 H.R. 1983

H.R. 1983 is about “Scope of Practice” not equity.
• While optometry has failed in their attempt to pass surgery privileges in 17 states since it passed in Oklahoma in 1998, they continue to press for licensure expansion into surgery.
• The inclusion of the word “surgery” in a national program’s description of their services will be used by optometry as a federal “stamp of approval” to pressure states which to date have refused O.D. state surgical initiatives to expand O.D. licensure to include surgical services.
• Inserting H. R. 1983 into the provisions of the current statute would be a highly unusual move. The statute in question only refers to physicians and dentists. No other health care practitioners are included in this section of the statute that optometrists are attempting to amend.

Federal intervention is unnecessary.
• In fact, current law (42U.S.C. 1396 (d)(a)(6)) permits funds to pay for “medical care, or any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of practice as defined by State law.”

The legislation is precedent setting.
• H.R. 1983 would amend a section of the federal Medicaid statute that describes medical and surgical services provided by physicians and dentists. No non-physician practitioners are included in that section.

Licensure scope is a states rights issue.
• There are significant questions over what optometrist state licensure permits in key states around the country. Optometric licensure and education varies considerably from state to state. Several states specifically prohibit surgery by optometrists yet optometric boards are demanding reimbursement for multiple surgical codes. These issues should be left to the state to work out. A Federal law that would require state Medicaid programs to reimburse optometrists for an unspecified mix of surgical procedures is not appropriate. It would limit state programs ability planning and control expenditures and leave taxpayers holding the bag.

The public wants to know who is the MD.
• The public is very confused over the difference between eye care practitioners and much of this is due to representation by optometry as physicians and surgeons even though they do not attend medical school. H.R. 1983 only adds to this consumer confusion.

Leading national physician organizations oppose H.R. 1983 including:
• American Medical Association
• American College of Surgeons
• American Society of Cataract and Refractive Surgeons





110TH CONGRESS 1ST SESSION
H. R. 1983

To amend title XIX of the Social Security Act to require Medicaid coverage
of professional services of optometrists that are otherwise covered when
furnished by a physician.

IN THE HOUSE OF REPRESENTATIVES
APRIL 20, 2007

Ms. SCHAKOWSKY (for herself, Mrs. BONO, Mr. BOOZMAN, and Mr. WYNN)
introduced the following bill; which was referred to the Committee on Energy
and Commerce

A BILL


To amend title XIX of the Social Security Act to require
Medicaid coverage of professional services of optometrists
that are otherwise covered when furnished by a physician.

1 Be it enacted by the Senate and House of Representa
2 tives of the United States of America in Congress assembled,
3 SECTION 1. SHORT TITLE.
4 This Act may be cited as the ‘‘Optometric Equity in
5 Medicaid Act of 2007’’. VerDate Aug 31 2005 16:41 Apr 22, 2007 Jkt 059200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H1983.IH H1983 sroberts on PROD1PC70 with BILLS

2​

1 SEC. 2. REQUIRING MEDICAID COVERAGE OF PROFES
2 SIONAL SERVICES OF OPTOMETRISTS THAT
3 ARE OTHERWISE COVERED WHEN FUR
4 NISHED BY A PHYSICIAN.
5 (a) IN GENERAL.—Section 1905(a)(5) of the Social
6 Security Act (42 U.S.C. 1396d(a)(5)) is amended—
7 (1) by striking ‘‘and’’ before ‘‘(B)’’; and
8 (2) by inserting before the semicolon at the end
9 the following: ‘‘, and (C) medical and surgical serv
10 ices furnished by an optometrist (described in sec
11 tion 1861(r)(4)) to the extent such services may be
12 performed under State law either by a doctor of
13 medicine or by a doctor of optometry and would be
14 described in clause (A) if furnished by a physician
15 (as defined in section 1861(r)(1))’’.
16 (b) EFFECTIVE DATE.—The amendments made by
17 subsection (a) shall take effect on the date of the enact
18 ment of this Act.

 

[Pastrami King]

FYI California state legislature just had bill 1406 introduced which would significantly expand the optom scope of practice. It was introduced on the last day that new bills could be considered.

This bill allows optoms (1) use of all topical medicines (2) minor surgical procedures not requiring general anesthesia, (3) any test or procedure necessary to the accurate diagnosis
or treatment of a condition of the eye or visual system," and (4) injections.

 

[jefguth]

You are correct. Optometrists are now taking it to the federal level to include the word "surgery" in their scope of practice. This is similar to methods used in the past to introduce new scope. While ODs will not be doing cataract surgery by the end of the decade, this slow movement towards changing legislation sets up the stage for optometric surgery in the future.

Included below is a new bill being considered at the FEDERAL LEVEL. Usually, scope of practice issues are dealt with at the state level. Here are some facts about this bill and the Amercian Academy of Ophthalmology's opinion.

Dr. Doan,

I fail to see how this bill does anything to change the optometric "scope of practice," it merely seeks to ensure that optometrists are paid by medicaid programs for procedures they are already permitted to perform in their individual states.

 

[oldManDO2009]

The arguments used by ODs is the same CRNAs are using against anesthesiologists. Once the flood gates are open, there's no stopping. they will continue to push until they are seen as equal in the eyes of the law.

Add NP's soon to be DNPs and every other medical profession. It seems that if the procedure is not within 3 minutes of your home then there is an access problem and every other profession should be allowed to offer the service. What starts out as simple eye surgery will be used to increase scope along with the argument of "where is the proof that we do not provide the same safe effective care as MD/DOs?" These are the 2 core arguments that permeate these discussions and as long as money is involved it will never end...

 

[Andrew_Doan]

Dr. Doan,

I fail to see how this bill does anything to change the optometric "scope of practice," it merely seeks to ensure that optometrists are paid by medicaid programs for procedures they are already permitted to perform in their individual states.

Federal intervention is unnecessary.

• In fact, current law (42U.S.C. 1396 (d)(a)(6)) permits funds to pay for “medical care, or any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of practice as defined by State law.”

 

[KHE]

Federal intervention is unnecessary.

• In fact, current law (42U.S.C. 1396 (d)(a)(6)) permits funds to pay for “medical care, or any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of practice as defined by State law.”

Regrettably, federal intervention IS necessary because while federal law may
"permit funds for medical care", the fact is that in many states ODs are excluded from providing anything other than routine or refractive care to Medicaid patients, or other state welfare programs despite holding a state license that grates them those privileges.

It's regrettable that a year old thread that has been so contentious has been needlessly resurrected but I think it's probably time that the two professions really start to get honest with themselves, and with each other.

The fact is that 99% of optometrists are not interested in surgery, or at the very least “true surgery.” Optometrists would like to be able to continue to do the “surgeries” that they have been safely and effectively doing for years, such as foreign body removals and punctual occlusion. Unfortunately, if the AMA continues to classify those procedures as “surgery” then I guess I am guilty as charged. I want to do surgery.

Yes, it is true that there is a small handful of optometrists that would like to pursue YAGs and PI and perhaps even LASIK, but the overwhelming majority of optometrists understand the economics of this situation. I am a partner in a progressive, “medically” oriented optometric practice and the number of patients I see on a monthly basis that would benefit from a YAG or a PI is so infinitesimally small, it would take me 40 years to pay off the laser, even if I COULD do them. It’s the same thing with LASIK. As I have said before on these forums, if you waved a magic wand tomorrow and granted every one of the 35000 optometrists in the USA the right to do LASIK, and if even only 10% of those pursued it, the economics of the situation would mean that you would essentially TRIPLE the supply of providers overnight while the demand would stay exactly the same. What is that going to do to the fees? We would look back on the days of the $299 per eye billboard advertisements as the “golden age” of refractive surgery. Most optometrists understand this.

Someone is going to bring up Oklahoma. I don’t live in, nor have I ever practiced there. I do not know how many optometrists in Oklahoma actually perform much surgery. My understanding is that 95% of the optometric surgery in Oklahoma is being performed by 2 doctors. I do not know if that is true or not. However, I have not seen or heard of any reports from Oklahoma showing a large spike in blindness caused by rogue optometrists brandishing lasers or scalpels. If there was, I am sure that we would see it trumpeted on the front page of Ophthalmology Times in 72 point print.

Someone is going to bring up the optometric physician moniker. Again, a silly thing brought about by medical insurers refusing to reimburse non-physician providers. The majority of optometrists don’t use this terminology even in states where it is legally permissible to do so, which is only a small handful. Walk into 99% of optometrists office, or look at 99% of optometric advertising and you will see the words “optometrist” and “optometry” all over the place. Some optometrists probably do engage in some form of puffery with this title, but it's not any different than the ophthalmolgist who opens up the "Johnson Vision Institute" run by surgeon Dr. Johnson who has people come from foreign countries to visit and train with him (means that his roomate from college who know lives in Canada stopped by on his way to Disneyworld for a visit) This is a rare occurance on both sides of the issue and the people involved in it really aren't fooling anyone.

Someone else is going to bring up the silly survey about how the general public doesn’t understand the difference between the two professions and how they want “only qualified physicians and surgeons” to treat medical eye conditions. As such, legislation was introduced requiring non-physician providers to essentially make a declaration to each patient they see saying something “Well you know Mrs. Jones…I DIDN’T go to medical school. I’m just a scummy mid level provider. If you want to see a REAL DOCTOR then I’m not your guy.” Obviously, it’s quite ridiculous, though interestingly enough it exempted certain other non-physician providers from having to make this declaration. Of course, the survey was also filled with loaded questions designed to give the result that it gave.

I could easily design a survey asking questions like “Who would you rather have treat your child’s pink eye? A doctor who spends 4 years studying the eye exclusively, or a doctor that spends two weeks studying the eye in medical school?” When the results come in 95% for the former, we should introduce legislation barring pediatricians from treating pink eye.

Obviously, that’s a ridiculous statement, but you can see how silly and stupid these battles get and how easy it is to design a survey to give you the result you want.

There are just so many issues affecting the two professions that if we actually united on them, we would see our patients better cared for, and our collective reimbursements rise.

Instead, we piss money away bickering amongst each other because we aren’t being honest with ourselves, or with each other. We are just having a big giant pig pile of chest thumping, and it’s really getting neither side anywhere. Quite unfortunate indeed.

 

[Andrew_Doan]

The fact is that 99% of optometrists are not interested in surgery, or at the very least "true surgery." Optometrists would like to be able to continue to do the "surgeries" that they have been safely and effectively doing for years, such as foreign body removals and punctual occlusion.

I wish California Optometrists felt the same as you stated. They are pushing a bill that basically allows them to do all minor surgeries. They even crossed our lasers and such which would allow them to do laser surgeries too.

The bill specifically modifed "Punctal occlusion by plugs, excluding laser, cautery,diathermy, cryotherapy, or other means constituting surgery as
defined in this chapter" with the following:

"Minor surgical procedures not requiring general anesthesia
and necessary to the diagnosis and treatment of a condition of the
eye or visual system."

State Senate Bill 1406 (http://www.leginfo.ca.gov/pub/07-08/bill/sen/sb_1401-1450/sb_1406_bill_20080221_introduced.pdf), a bill sponsored by the California optometry lobby, has been introduced into the state legislature to authorize optometrists to perform nearly all eye surgery.

SB 1406 would authorize the Board of Optometry to allow optometrists to perform:

LASIK
Cataract surgery
Glaucoma/filtering/valve surgery
Blepharoplasty
Retinal/vitreous surgery
All laser procedures (PRP, ALT, etc.)

 

[Oculomotor]

see post below....

 

[Oculomotor]

Dr. Doan, this is another reason among many reasons for the Ophthalmology profession to stop it's derogatory attacks on optometry (New Mexico Legislature scolded the AAO for it's irresponsible scare tactics used to convince the public, especially children, that OD's were harmful in providing eye care period.....the "minor surgical procedures bill" still passed. In 35 years of this "mud-slinging" Optometry's scope still expands slowly but surely. My home state just got narcotics for eye pain (just like 42 other states) and oral steroids (just like 45 other states). Being a legislatively active optometry student who plans on getting as much training as possible---> peri-ocular injections, eye disease residency in VA, etc....., I feel as if the ONLY way this will EVER be resolved will be something similar that you suggested in one of your posts back in 2005----> a legitimate optometric surgery residency. Dentistry has OMS, Podiatry has a 4 year orthopedic surgery residency, optometry needs one so the 1-2% of OD students that desire such a thing have the opportunity. Define the boundaries by having a surgical track----> 3rd year of OD school take the USMLE Step 1 enter a 1year of selective medical school rotations (internal medicine, ophthalmology, etc....) then take USMLE step 2, go to a (newly created ----optometric surgery residency---maybe limiting surgery to the anterior segment) for 3 years........Problem solved. You will still have MOST ophthalmic surgeons being ophthalmologists and a handful of OD Surgeons (anterior segment surgeons) BUT establishing a precedent for optometric surgery OTHERWISE you will have a piece-mill battle in every state for YEARS and ophthalmology has (in general) since 1971 not been successful--->supply and demand dictates this (75% of eye care is provided to this country by doctors of optometry. I have no sympathy for ophthalmology honestly-----> I have sat in on some of the legislative battles in my home state and have heard the demeaning rhetoric from the state ophthalmology society with NONE whatsoever from the optometry side in regard to ophthalmology. I just shook my head and thought to myself," that is a real low blow from a professional organization that is not going to help them prevent this bill from passing!" You are a leader in the field of ophthalmology and a well respected ophthalmic surgeon----> suggest a legitimate pathway for optometric surgery so this will not happen anymore....(you had that idea two years ago Dr. Doan) I don't think it will ever happen due to the undeniable hubris of ophthalmology and the large pride of optometry.

 

[Caffeinated]

You are a leader in the field of ophthalmology and a well respected ophthalmic surgeon----> suggest a legitimate pathway for optometric surgery so this will not happen anymore....(you had that idea two years ago Dr. Doan) I don't think it will ever happen due to the undeniable hubris of ophthalmology and the large pride of optometry.

It seems that you have already outlined what you consider to be a "legitimate pathway for optometric surgery" in your post. You then proceed to ask that Dr. Doan suggest his version as a way of giving validity to the concept of optometric surgery. If, as you suggest, a new pathway were created, the OD-surgeons would not be content to be anterior segment surgeons, when there is a class of MD/DO surgeons that are not confined by anatomic boundaries. Your solution is not a recipe for peace and harmony; it will sew the seeds of an new season of legislative battles that the next generation will inherit.

For those optometrists who desire a surgical pathway, there is one that already exists -- go to med school. There are some med schools that have independent study programs in which you can complete your pre-clinical courses in 1 year, and graduate in 3 yrs. Some might argue that it is unfair to make someone spend 7-8 years after optometry school in order to become a surgeon. But having been through both programs, I think a highly motivated individual with an optometric education could get through the first 2 years of med school in 12 months. Beyond that, there is not really much else that can be compressed or eliminated to shorten the program without sacrificing the training of the future surgeon.

I have worked with physicians across many disciplines (including general surgery, trauma surgery, cardiothoracic, vascular, neurosurgery, emergency medicine, OB-Gyn, critical care, etc). On the spectrum of "undeniable hubris" (which will hereafter be known as "UH"), ophthalmology generally scores pretty low compared to other specialties. Of course, this is a generalization, and there tends to be Gaussian distribution of UH within each profession. But I think you will find that the mean UH score for ophthalmology is relatively low compared to most other medical specialties.

Caffeinated

 

[Jake the Snake]

suggest a legitimate pathway for optometric surgery so this will not happen anymore....

I have an idea. We close down all optometry schools and simply allow ophthalmologists to provide complete eye care. Problem solved.

 

[Oculomotor]

Jake the Baby Snake,

Grow up. How old are you?----like 23 or something----real constructive comment little man. Did you leave the fraternity party last week? Right now you are in medical school and taking "hook line and sinker" all of the indoctrination and superiority nonsense down your throat. Hmmmmm, let's see I will make a comment as STUPID as yours, "Let's make a law that forbids ophthalmologists from performing primary eye care---it is not their area anyway." There, now I am as stupid and imature as Jake the Snake!


Good luck Jake you will need it when in 2013 to 2015 whenever you are done with your residency you will be practicing in a world of even more scope expansive optometrists, independent DNP's (Doctorate nurse practitioners), and a severely reduced reimbursement rate due to managed care! good luck little man.

• By the way, one of my best friends from childhood is an ophthalmologist and he's pretty cool

A man in his 30's becoming a doctor of optometry......enough said

 

[Oculomotor]

Caffeinated,

I respect your opinion and you have a wealth of knowledge and I might add a very educated response. I still feel though that the OD's that want surgery are not going to accept that solution. If I was one of the future OD's who wanted surgery, I would not re-enroll another clinical doctorate program after busting my tail for 4 years to get my current clinical doctorate (OD). I think a lot of people would think the way that I do. Dr. Doan made a recommendation in 2005 on this site about an optometric pathway to surgery-----look it up. It was a sound idea.



Good luck to you in Ophthalmology and please stay true to your OD roots!

 

[KHE]

Jake the Baby Snake,

Grow up. How old are you?----like 23 or something----real constructive comment little man.

I strongly urge everyone to ignore this persons comments...IIRC, he has just completed his first semester of optometry school and is not in any position to provide any where near an adequate frame of reference on any of these issues, though I know he thinks he does because he will likely blather on about all the MDs in his family or all of his close friends who are ophthalmologists.

 

[Jake the Snake]

Jake the Baby Snake,

Grow up. How old are you?----like 23 or something----real constructive comment little man. Did you leave the fraternity party last week? Right now you are in medical school and taking "hook line and sinker" all of the indoctrination and superiority nonsense down your throat. Hmmmmm, let's see I will make a comment as STUPID as yours, "Let's make a law that forbids ophthalmologists from performing primary eye care---it is not their area anyway." There, now I am as stupid and imature as Jake the Snake!


Good luck Jake you will need it when in 2013 to 2015 whenever you are done with your residency you will be practicing in a world of even more scope expansive optometrists, independent DNP's (Doctorate nurse practitioners), and a severely reduced reimbursement rate due to managed care! good luck little man.

• By the way, one of my best friends from childhood is an ophthalmologist and he's pretty cool

A man in his 30's becoming a doctor of optometry......enough said

You really painted a great picture of OMDs being the bad guys and talking bad about ODs etc, then you come back with a post like this? Why should I be able to listen to your ideas about an OD/surgical residency, but you not listen to mine about getting rid of ODs alltogether? (which was actually suggested here on SDN in the past by a current OD turned OMD) The point is we both have ideas and as educated folk (and by the way, I am 30 y/o), we should both be inclined to hear the other's arguments without resorting to middle school name quarls.

I stand by my idea. Why do we need ODs? What is the problem with closing all OD schools and increasing the number of OMD residency spots? It seems like this would solve many problems. Patients would have access to more eye care physicians who could treat almost all eye issues. Residency would be become less competitive due to the increased spots. Pay would stay the same since OMDs would replace ODs (not on a 1:1 ratio, but enough to keep salaries stable).

I know you don't like the idea, but if you can come up with one that's better for not only patients, but the folks involved in eye care, I'm all ears.

 

[KHE]

I wish California Optometrists felt the same as you stated. They are pushing a bill that basically allows them to do all minor surgeries. They even crossed our lasers and such which would allow them to do laser surgeries too.

The bill specifically modifed "Punctal occlusion by plugs, excluding laser, cautery,diathermy, cryotherapy, or other means constituting surgery as
defined in this chapter" with the following:

"Minor surgical procedures not requiring general anesthesia
and necessary to the diagnosis and treatment of a condition of the
eye or visual system."

State Senate Bill 1406 (http://www.leginfo.ca.gov/pub/07-08/bill/sen/sb_1401-1450/sb_1406_bill_20080221_introduced.pdf), a bill sponsored by the California optometry lobby, has been introduced into the state legislature to authorize optometrists to perform nearly all eye surgery.

SB 1406 would authorize the Board of Optometry to allow optometrists to perform:

LASIK
Cataract surgery
Glaucoma/filtering/valve surgery
Blepharoplasty
Retinal/vitreous surgery
All laser procedures (PRP, ALT, etc.)

Again, I can not speak for the political process in California, but the collegues that I know who DO practice in California report that it is essentially the land of VSP and lack of HMO access. I am 100% certain that the intention of this bill is NOT so that ODs can suddenly run off and start doing blepharoplasties and valve surgeries. No hosptial or ASC is going to credential any OD to perform these procedures though they may technically be licensed to perform them in the exact same way that no hospital is going to credential a gastroenterologist to perform a vitrectomy. Your argument also presumes that optometrists are so reckless that if the were techically granted these rights, that they would all run out en masse and assault the unsuspecting public with their untrained surgeries.

We need to be honest with each other about this.....this whole discussion IS all about money. But contrary to what you may think, it is NOT about the money that could be potentially made from performing these procedures. Again, if we triple the supply of providers for a procedure, yet the demand stays the same, what is that going to do to the reimbursement?

The issues that optometrists REALLY want are:

1) Access to medical plan reimbursements

2) The ability to REASONABLY grow and evolve as techology and theraputic modalities evolve. We don't want to have to grovel before the medical board everytime some new eye drop comes on the market.

3) Our patients back when we refer them to ophthalmologists. Far too often, our patients simply get sucked into the opthalmology vortex. Now...I know, I know....you are all going to say that many times the patients request to stay with the ophthalmologist and we all know that sometimes that is true and that is just fine because most optometrists don't want the advanced diabetic patient with endstage glaucoma and Eale's Disease.

But this is the part where we need a little bit of honesty from the ophthalmolgists.....we all know that far too often, there is absolutely NO effort made to get the patient back to the referring doctor for ongoing care and far too often it is actually discouraged though there is no reason for it to be.

Now....if the only way that we can get our patients back from an ophthalmologist after a chalazion removal is to fight for the right to "perform surgery" and just do the chalazion removals ourselves, well then that's probably going to have to happen.

But the reality of it is is that there is no reason to dance these silly dances and just make a bunch of lawyers and lobbyists rich. I am not a spokesperson for the profession of optometry in any way but I honestly feel that many of these issues can be worked out relatively easily with some give and take on both sides. Optometrists would be willing to exclude invasive ocular surgeries if ophthalmologists would acknowledge that an OD is more than capable of removing a small piece of metal from a cornea and that that hardly rises to the level of "surgery." Optometrists would be willing to give up silly titles like optometric physician if ophthalmologists would lend a bit of a hand with medical insurance credentiallling.

 

[KHE]

You really painted a great picture of OMDs being the bad guys and talking bad about ODs etc, then you come back with a post like this? Why should I be able to listen to your ideas about an OD/surgical residency, but you not listen to mine about getting rid of ODs alltogether? (which was actually suggested here on SDN in the past by a current OD turned OMD) The point is we both have ideas and as educated folk (and by the way, I am 30 y/o), we should both be inclined to hear the other's arguments without resorting to middle school name quarls.

I stand by my idea. Why do we need ODs? What is the problem with closing all OD schools and increasing the number of OMD residency spots? It seems like this would solve many problems. Patients would have access to more eye care physicians who could treat almost all eye issues. Residency would be become less competitive due to the increased spots. Pay would stay the same since OMDs would replace ODs (not on a 1:1 ratio, but enough to keep salaries stable).

I know you don't like the idea, but if you can come up with one that's better for not only patients, but the folks involved in eye care, I'm all ears.

This posting is exactly the reason why this issue should NOT be debated by medical students and optometry students because NEITHER OF THEM have ANYWHERE near an adequate from of reference to form an opinion on anything despite how many family members they have as MDs or how many hours they have spent shadowing this OD or that ophthalmologist.

 

[Faebinder]

Eye glasses... That's the issue. No money it and really no glory (I mean after 4 years of med school and 4 years of training including for codes and life/eye threatening emergencies do you really want to sit in the office and tell an 89 year old guy he needs a slightly stronger prescription?) Ophthalmologists wont do them. They will refer you to an optometrist.

Optometrists feel their work is not reimbursing them enough, they want the better procedures. So they expand into a scope that they aren't set to do. They see most of the patients and hold the key of referrals.

The states want whichever is cheaper but somewhat good. They don't care about either professions, as long as the patients are generally happy (1 or 2 going blind from a mistake is no big deal, we'll just call the providers "negligent"). Heck, both groups might give the state support so they can lean towards them over the other side, so the fight is good for the state. It creates "competition".

Unavoidable final result: A pathway for Optometrist will be created, like podiatry with orthopedics unless ophthalmology pulls a miracle. I donno, something like lasix for everyone for cheap that way no one needs eye glasses anymore? Or maybe start having primary care do some of the eye care. Maybe some fellowship.

My solution: Integrate them before it's too late.

Did I summarize it well?

 

[Andrew_Doan]

I think a reasonable approach is having a specific pathway for OD's to apply to ophthalmology residency programs that are willing to work with associated medical schools. For instance, OD's apply for residency at allopathic and osteopathic (MDs and DOs programs). When accepted:

1) The candidate goes to medical school for 2 years covering the clinical material that all medical students must cover and pass before internship.

2) Complete a 1-year internship in a medical specialty.

3) Matriculate into the residency program with now "OD, MD" or "OD, DO" degrees.

This will assure that any surgery performed by ophthalmic surgeons is regulated by educators that have expertise, programs, and facilities to properly train surgeons. IF we do something like this, I feel that the 1% of ODs who decide that surgery is the thing they want to do will have a means to do it. This also allows the power of granting surgical privileges to remain with the state medical boards and NOT with non-MD state boards.

 

[Caffeinated]

I think a reasonable approach is having a specific pathway for OD's to apply to ophthalmology residency programs that are willing to work with associated medical schools. For instance, OD's apply for residency at allopathic and osteopathic (MDs and DOs programs). When accepted:

1) The candidate goes to medical school for 2 years covering the clinical material that all medical students must cover and pass before internship.

2) Complete a 1-year internship in a medical specialty.

3) Matriculate into the residency program with now "OD, MD" or "OD, DO" degrees.

This will assure that any surgery performed by ophthalmic surgeons is regulated by educators that have expertise, programs, and facilities to properly train surgeons. IF we do something like this, I feel that the 1% of ODs who decide that surgery is the thing they want to do will have a means to do it. This also allows the power of granting surgical privileges to remain with the state medical boards and NOT with non-MD state boards.

Under the current system, an OD applicant would spend 4 years in med school, 1 year in internship, and 3 in residency, for a total of 8 yrs. The program that Dr. Doan suggests is different in only 2 ways:

1. It cuts med school time down to 2 yrs.

2. Applicants are pre-selected to ophthalmology at the time they apply to med school.

First, let's examine #1. If the 2 yrs spent in med school are exlusively clinical years, this would be based upon the assumption that an optometric education covers everything that is covered in allopathic or osteopathic pre-clinical years. This is not the case, and some of the fast-tracked med school time would need to be in didactic learning. A reasonable estimate is that an ambitious applicant could cover the didactic material in 12 months, and perhaps the clinical years could be shortened to to 1.5 years if electives were eliminated. This is only 6 months shorter than doing med school in 3 yrs, which is a limited option that already exists.

Next, let's examine #2. Ophthalmology residency is competetive for the traditional applicants, and there does not seem to be a shortage of applicants. If you start guaranteeing pre-selected slots for OD applicants, then qualified traditional applicants will have less slots with which they all have to compete. Alternatively, the system would need to expand the number of ophthalmology slots to accommodate the OD-MD applicants.

But what happens when the OD-MD applicant decides that they don't really want ophthalmology? Or perhaps they do ophthalmology residency and then go back and decide to do another residency? Now that they have steps 1-3, and MD/DO degree, and an internship, shouldn't they be allowed to apply for internal medicine, anesthesia, etc? Now we are forcing all other medical specialties to accept these applicants into the system that ophthalmology agreed to.

Creating a new curriculum would be very time consuming and labor-intensive. I am not sure if the cost-benefit ratio is practical when the new curriculum saves only 6-18 months compared to the current system. Especially in a market where there seems to be plenty of traditional med students that would like to go into ophthalmology.

 

[KHE]

Creating a new curriculum would be very time consuming and labor-intensive. I am not sure if the cost-benefit ratio is practical when the new curriculum saves only 6-18 months compared to the current system. Especially in a market where there seems to be plenty of traditional med students that would like to go into ophthalmology.

I basically agree with this. It's a resonable idea in theory but in practical terms it makes little sense because of the cost factor, the time factor, and the likelihood that so very very few ODs would pursue a program like this because so very very few ODs wish to actually perform these procedures. The ones that do need to just get over it and pursue the traditional route if they so desire.

The issues remain what I outlined above.

 

[oldManDO2009]

My issue is with scope of practice. CRNA are trying to get licensed for fluoroscopy to place central lines? Anybody who has placed a line know fluoroscopy is overkill and at most ultrasound would be sufficient. It is clear that once licensed for "line placement" injctions for pain mgt are next. So this idea that they could not get credentialed is not the goal - just get approved and create the clinical opportunity down the road.

Surgery is the realm of surgeons and must require medical school. This constant attack to increase scope is making me dizzy.....