http://www.revoptom.com/archive/issue/ro05gued.htm
GUEST EDITORIAL
Will Professional Myopia Destroy Us?
by David Phillips, O.D., Blue Springs, Mo.
I may not renew my Optometric license next year. I've been thinking of becoming an optician instead. A refracting optician.
Don't get me wrong. I love optometry. I started practice before diagnostic drugs, and nearly half my professional life was pre-TPA. I have a deep appreciation for how we've emerged as a true primary eye-care profession.
But it seems to me that optometry has lost its way. Traditional vision care just isn't glamorous any more. We've gotten into a mind set that demands an ever-expanding scope of practice?glaucoma this year, lasers next year, who knows what after that? We obsess about how many Rxes O.D.s are writing, and our journals fill themselves with more and more esoteric primary care.
I'm not advocating that we abandon primary care. But clinical vision care is more important to the survival of our profession than expanding the primary care boundaries. Given that there are many times more patients who need refractive care than need medical eye care, reality dictates that we are dependent on the former for our very existence.
Opticians, meanwhile, are hoping we will be so myopic as to ignore refracting and clinical vision care long enough for them to get a foot in the door. With ophthalmology's move into dispensing and managed care's desire for one-stop service, independent opticians who cannot generate their own Rxes are fighting for survival. Many among them think that refracting will be their salvation. Opticians have introduced a bill in Washington State that would allow them to refract. Similar legislation may soon be sought in Florida, New York, Nevada and Texas.
This legislation would allow refraction only "under supervision" or with other limitations. We cannot allow ourselves or our legislators to be misled; opticians' ultimate goal is to gain licensure to perform independent refractions.
What can we do? Let's examine the hollow arguments opticians have used to confound the issue:
? Eyes are healthy if they can be refracted to 20/40. I can think of 9.2 million reasons why this one is not true.1 Under the Washington bill, opticians could alter a prescription in patients having best-corrected acuity of at least 20/40. This implies that the eyes are healthy if they can be corrected to 20/40. Otherwise, why place a limit on acuity? But we know that no level of visual acuity proves the eyes are healthy. Acuity is not a test of eye health.
A short list of eye diseases that can be present in an eye with 20/25 or even 20/20 acuity: glaucoma, retinochoroiditis, diabetic retinopathy, histoplasmosis, wet age-related macular degeneration, Coats' disease, Stargardt's disease, choroidal tumor, pigmentary dispersion syndrome, pseudoexfoliation cataract and retinal detachment.
? Opticians are "eye care professionals." This is simply not true. It's a trade at best, but even if trades were outlawed, in most states opticians couldn't get arrested. Opticians are unlicensed and unregulated in 28 states. In states that do require a license, not all require a high school diploma. Only three states require any college education. There are two professional "O's," not three.
? Opticians will be "well-patient" refractionists. How this can be when opticians are not clinicians and are not qualified to tell whether or not a patient is well? A leading optician said it was "totally irrelevant" when confronted with a case where an optometrist saved an asymptomatic patient's life by discovering a choroidal melanoma on a routine dilated exam2 because the patient went in for an eye exam, not just a refraction.3 This ignores the obvious: Since independent optician refractions are not allowed, this patient did not actually choose a complete exam over a separate refraction. Our system forced him to have the exam, even though he was asymptomatic, and it saved him from the fatal mistake of having an optician "tweak" his Rx?and letting his malignancy go undiscovered. This is why the complete exam, and just not refraction, is the standard of care. It should not be changed.
? Opticians should not be held accountable for failure to diagnose, because they will be doing refractions, not exams. How great for them! But if opticians are asking to be allowed to provide a facet of health care, why shouldn't they, unlike all other health-care providers, be held accountable?
? We need optician refractionists. There is actually a surplus of eye doctors, all of whom are trained to refract. The Rand study found up to 30 percent more O.D.s than are needed.4 The oversupply of ophthalmologists is so bad that the Health Care Financing Agency is now offers subsidies to the nation's 1,250 teaching hospitals to cut back ophthalmology residencies.5
? Refracting opticians would be cost-effective. In other words, the laymen are telling the doctors that preventive medical care is not cost-effective. But we know that if we let disease go until the later stages, it is more difficult and more expensive to treat.
? Opticians could become competent refractionists with a 100-hour course. The magician's trick of misdirection. They want to shift the argument to whether they could learn to refract, when the only legitimate question is whether they should. It doesn't matter whether opticians could learn to use the phoropter, one of the eye doctor's tools, in 100 hours or even 1,000 hours. Without an eye health exam, it is a statistical certainty that a number of their "patients" will have an undiagnosed ocular and/or systemic disease to go with their new glasses.
I could spend 100 hours teaching my 17-year-old how to look up medications in the Physician's Desk Reference, another one of our tools. She could become quite competent at finding indications, side effects and interactions for various drugs. But would this make her qualified to prescribe medication for patients? Of course not.
? The opticians' 100-hour refractometry course is comparable to our 100-hour DPA or TPA courses. However, a 100-hour post-graduate course for doctors is an entirely different matter than some beginner training for non-professionals. The truth is that optometry had a generation of medically trained graduates in place before seeking an expanded scope of care. Opticianry has no such educational basis for laying claim to expanded privileges.
? Opticians "gave up" refraction decades ago. Refracting represents progress, or is a natural evolution for them. They have the history backwards. Present-day opticians are "descended" from those turn-of-the-century opticians who did not pursue refraction. Those who did pursue refraction became optometrists. There is no need to have a second batch of opticians branch off and evolve, over the next 100 years, into eye doctors. It's already been done.
? Because lay people can self-prescribe reading glasses, opticians should be able to write Rxes for glasses. This is one of my favorites. Let's follow the logic: Neosporin ointment can be purchased over the counter, so lay people can self-prescribe meds. Therefore opticians should prescribe meds!
Every O.D. should strongly oppose independent refractometry for opticians. We have a duty to every patient we examine to look after his or her health and well-being. I believe we have an equal duty to protect the public, for its own economic benefit, from having unqualified examiners doing part of the job.
Besides the public health issue, consider what would happen if opticians can refract. Sooner or later the managed-care folks will discover they can get such refractions cheaper than an eye exam. Managed care already tells the patients who to see and how often. If managed care decides that optician refractions are OK for routine care and that people only need a doctor's eye exam every four or five (or six or eight!) years, how many surplus O.D.s are there going to be then?
We must make sure our state leaders keep this matter uppermost in mind. History has shown that wars fought on two fronts are rarely won; lasers, orals, injectibles and so forth, must not be won at the expense of traditional refractive care.
Dr. Phillips is in solo practice. Since graduating in 1975, he has practiced in a military hospital, private optometry offices, private ophthalmology offices and in an independent retail optical store. His e-mail is
[email protected]
1. Sherman J. The $9.2 million misdiagnosis. Optom Mgt 1997; 32(5): 66-7.
2. Phillips D. Why Opticians Won't Refract. Eyecare Bus 1997; 12(8): 34-8.
3. Appler T. "Opticians Are Refracting." Eyecare Bus 1997; 12(8) 34-8.
4. Too Many O.D.s, Too Many M.D.s, Rand study finds. Rev Opt. 1994; 131(12):5.
5. Feds Start Anti-Residency Program. Rev Ophthalmol 1997; 4(10):6.
