Future of Ophthalmology?

[John_Doe]

Maybe it is just a pipe dream, but wouldn't be better if ophthalmology and optometry combine forces, contingent upon optometry stopping their scope of expansion into becoming a non-physician ophthalmologist, to fight opticians expansion into the refractive realm and other issues. But I doubt optometry will be satisfied with their current scope of practice. And even if optometrists become equivalent in scope of practice to general ophthalmologist, optometrists have most to lose if opticians begin a primary role in vision care which would include refractions/prescriptions: opticians will refer to ophthalmologists before optometrists for any further eye care needs such as cataracts, glaucoma, surgical refractive care, etc (and this will be a powerful referral network because they will serve as early gate-keepers) - and likewise ophthalmology will refer refractions etc back to those who are not constantly fighting ophthalmology for increased scope of practice. What is so ironic about all this expansion of scope of practice, is the lack of figuring out what is best for the patient - the thrust of all these movements are economical and political. We can either choose to work together for stability in how patients are managed, or just duke it out without much concept of what the future will hold.
-----------------------
Take a look at Tampa 2004 AOOPT Meeting Agenda for optometry:

Will Refraction by Optometrists Survive the 21st Century?
Will technological advances, statutory changes, delegation to assistants, challenges by opticianry, and reversal of public policies result in the demise of refraction in optometry? This course will present the case against optometrists and offer suggestions and strategies for the future.

Botulinum Toxin: From A to Z
This course reviews Botulinum Toxin as it is used in various medical modalities. Highlights include facial dystonia, strabismus, headache and cosmetic uses. Injection strategies will be presented. The author has used Botulinum Toxin in his practice for over 13 years.

What Do You Mean I?m Going To Look Yellow? ? Fluorescein Angiography
The purpose of this lecture is to educate practitioners on fluorescein angiography (FA) and its use in the eye care profession. Different ways to administer this diagnostic test are presented, including both oral and IV. Digital video is used to demonstrate the phases of filling, and various conditions in which FA is used.

Therapeutic Drug Update - Clinical Applications
This course reaches the cutting edge of contemporary medical management with drugs used to treat eye disease. Reviewing all relevant drug classes and latest information, clinical application of pharmaceuticals is stressed with case studies.

Problem Post-Ops
Five eventful post-operative cases are presented to instruct attendees to recognize, correctly identify and appropriately manage significant post-operative complications.

There is More to Diabetes Than Meets the Eye: A Primary Care Optometry Overview
Diabetes and its associated retinopathy is a leading cause of visual disability and blindness that optometrists deal with daily. This course presents an overview of the systemic effects of diabetes, its diagnosis, and its current treatment from a primary eye care provider viewpoint. Pertinent research studies are reviewed.

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Members don't see this ad.

 

[speyeder]

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.

Sounds like a taste of their own medicine. It's hypocritical for optometrists to cry foul when opticians want to expand their scope of practice, yet many of their own colleagues are trying to do the same by lobbying for surgical rights.

 

[vanelo]

Once a patient is refered out, often times that patient is never seen again, even for primary eye care.

Doesn't that tell you something???? Believe me when I tell you I have seen many patients that visited their ophth's office and expressed their discomfort and lack of trust for their optometrist. And why shouldn't they feel this way? Everybody knows ophth's will ALWAYS be more prepared to handle situations than even the best optometrist. I am sorry for all of you optometrist who don't think so and keep lobbying to earn privileges but that is just the way it is.

 

[GlaucomaMD]

If you have a family doctor, and you need bypass surgery, you will ultimately end up back at your family doctor. Far too often, that's not the case with eye care. Once a patient is refered out, often times that patient is never seen again, even for primary eye care. On rare occasion, we might get a letter back. If OMDs were a bit more courteous in this area, a lot of this fighting probably wouldn't be needed.

There are some OMDs who are very good at making sure our patients are sent back, and those are the ones I try to refer to.

Jenny

I am very surprised that you do not get a letter back from ALL of the OMDs you send patients to - I am almost inclined to think that some of these patients are not telling OMDs that they are referred from you. I'll tell you why...

I say this mainly because (as someone already mentioned) it is absolutely criticial to keep your referral base happy (including ODs as well as general ophthalmologists as I am a glaucoma specialist) but also (and I daresay more importantly for some in our profession more obsessed with $$$) because we cannot bill a visit as a consult (which pays a lot more than a new patient visit) unless we send a letter back to the referral person. It is pretty strict such that a direct phone call is not even adequate. In fact, OMDs are committing insurance/Medicare fraud if they bill for a consult but not send a letter.

I always make a point to dictate a detailed letter describing my findings, impressions, and plan/recommendation back to the referring person, whether OD or another OMD. I do this even if I talk to him/her.

I also recommend patients to return to their regular OD/OMD unless
1. they need surgery (in which case I would send the patient back after they are stable post-op; sometimes I am forced to send patient back sooner than I'd like because they live too far away, etc.)
2. they do not want to return to the referring person (even then, I try to recommend another general OD/OMD closer to their home)

Remember it's not appropriate for OMD to bill for a consult if they intend to KEEP the patient -> then, it's considered truly "referral" and should be billed as a NEW PATIENT, not a CONSULT. CONSULT implies "helping" another provider with an issure with intent to return the patient back to them...

Fine point, but nonetheless important point, that is often not taught until you are out practicing...

Forgot to mention...

I wouldn't mind if I never had to refract my patient - just wish all my patients came referred to me with adequate refraction... Get to work, you ODs!

 

[odieoh]

I have a question for the OD's who want to expand their scope of practice--When you were applying to and attending optometry school, did you not understand what did and did not fall within the bounds of optometry? If you wanted to do surgery why not just go to med school? It seems ridiculous to want to create a back door into the surgical realm. You knew what you were getting into when you went to school, if you are now unsatisfied with your scope of practice, well, thats just too bad. Same goes for opticians. This attempted upward erosion into higher fields is very disturbing. Just my two cents.

 

[JR]

I actually think it makes perfect sense: why go through the rigorous medical school training and residency if you can lobby for surgical privillages as an OD ?!

 

[odieoh]

I actually think it makes perfect sense: why go through the rigorous medical school training and residency if you can lobby for surgical privillages as an OD ?!

Good point JR. I've always wanted to fly airplanes and yesterday I found a pilots license in a box of cracker jacks. All I need now is to spend some cash on some good lobbyists and if all goes well maybe I'll be able to fly myself around to interviews this year.

 

[paulyod]

As I have already stated, in my home state of New York, OMDs won an injunction a few years back restricing ODs from performing foreign body removals because that was "surgery" even though ODs had successfully removed thousands throughout the state. It wasn't a coincidence that the state court judge who issued this injunction happend to have a brother-in-law who was an OMD. It was eventually overturned after 6 months, but for those 6 months, many patients were denied care from the doctor of their choice, for a problem that their doctor could easily have taken care of. IMHO, the removal of superficial foreign bodies, punctal occlusion, and the injection of chalazions with Kenalog does not constitute surgery.


AS an OD in NY also, I have had to remave many FB's while working for a local OMD who was on call but couldn't be bothered to come in. No complications to the FB removals. Since I left his office, he'd be the first one to be down my throat if I removed another FB. Article 143 in the NY state office of professions defines what OD's can perform.

The practice of the profession of optometry is defined as diagnosing and treating optical deficiency, optical deformity, visual anomaly, muscular anomaly or disease of the human eye and adjacent tissue by prescribing, providing, adapting or fitting lenses, or by prescribing or providing orthoptics or vision training, or by prescribing and using drugs. The practice of optometry shall not include any injection or invasive modality. For purposes of this section invasive modality means any procedure in which human tissue is cut, altered, or otherwise infiltrated by mechanical or other means. Invasive modality includes surgery, lasers, ionizing radiation, therapeutic ultrasound and the removal of foreign bodies from within the tissue of the eye. Nothing in this section or section seventy-one hundred one-a of this article shall be construed to limit the scope of optometric practice as authorized prior to January first, nineteen hundred ninety-five. The use of drugs by optometrists is authorized only in accordance with the provisions of this article and regulations promulgated by the commissioner


Becareful JennyW what you do.....

 

[John_Doe]

Check out January 2004 at http://www.navao.org/ - and also take a look at the following letter -
SAMPLE LETTER FOR SENATE

Dear Senator:

I have learned that organized ophthalmology has prevailed upon Representative John Sullivan to introduce legislation to restrict the practice authority of optometrists within the Department of Veterans Affairs (VA). As a VA optometrist I find this . While no comparable legislation has been introduced in the Senate, I would like you to know that H.R. 3473 is a serious and unwarranted attack on my profession and my ability to provide appropriate eye care services to my veteran patients.

The VA has in place policies that govern the credentialing and privileging of independently licensed professionals including medicine, dentistry, podiatry and optometry. These policies reflect current clinical care standards that have been developed on the basis of millions of patient encounters. They ensure patient safety and veteran access to care.

H.R. 3473 would ignore the current standard of care and arbitrarily restrict the ability of VA optometrists to provide appropriate health care to our veteran patients. Procedures that VA optometrists are licensed to perform and have been providing to our veterans would be eliminated if H.R. 3473 were enacted. These are procedures that many of us perform on a daily basis and would be available to the veterans by optometrists practicing in the private sector. This would not only limit access to eye care, increase waiting times and require veterans to travel greater distances to receive care at great inconvenience to them, but would also restrict the care that veterans may receive relative to the private population. This would also increase the costs for providing these services.

You may be asked to consider legislation similar to H.R. 3473. I strongly urge you allow the VA health system and the State Boards of Optometry to work and oppose any legislation like H.R. 3473.

Sincerely,

 

[John_Doe]

Is this just to learn about FB removal, chalazionectomy, and epilation?
http://images.google.com/imgres?img...view+of+ophthalmology&hl=en&lr=&ie=UTF-8&sa=N


Another Optometry School Seeks to Establish Surgical Center

The Illinois Health Facilities Planning Board approved a Certificate of Need application filed by the Illinois College of Optometry and its clinic subsidiary, the Illinois Eye Institute, to construct a two operating-room ambulatory surgery center on the south side of Chicago, as part of the school?s campus.

The state board approved the CON permit contingent upon ?the continuance of an existing affiliation between the College of Optometry and the University of Chicago Department of Ophthalmology and Visual Science,? says Jeffrey S. Mark, executive secretary of the planning board.

Through this affiliation, Mr. Mark says, the ICO expects the ophthalmologists and residents from the University of Chicago to transfer all duties to the new surgery center where they will perform approximately 1,200 surgical procedures annually.

The approval has ignited a controversy in the ophthalmic medical community. Opponents of the optometry ASC say that there is no need for the surgery center because of the similar services already provided by the many nearby hospitals such as Mercy Hospital and Medical Center, Cook County Hospital, Rush-Presbyterian-St. Luke?s Medical Center and the University of Illinois Eye & Ear Infirmary. ?These are all facilities within a couple of miles or a 30-minute drive from the University of Chicago and the proposed location of the new optometry ASC,? says Richard Paul, executive director of the Illinois Association of Ophthalmology. ?There is no shortage of ophthalmic surgery capacity in downtown Chicago,? he says.

Others opposed to the building of the ASC contend that these health-care facilities are operating at only 80 percent capacity, and they worry that the surgery center will reduce their patient volume further and harm them financially.

?If the ASC is built, and it turns out that the cases coming from the University of Chicago alone aren?t enough to keep the new facility viable, what would stop the ICO from soliciting other cases from that part of the city?? asks Mr. Paul. ?Would the [neighboring hospitals] lose their referrals to the ASC if it needs more cases??

Unfortunately, these questions remain answered.

Richard Cerceo, executive vice president and chief operating officer of Mercy Hospital and Medical Center in Chicago, a facility that is approximately within a mile and a half from the proposed ASC building site, believes that ?adding more capacity to the [health-care] system will just lessen operational efficiencies from the reduction of [patient] volume. The ICO has given us no assurance that the ASC will rely exclusively on patient volume from the University of Chicago.?

Building another medical center down the street may appeal to some ophthalmologists, says Mr. Cerceo, but, like Mercy Hospital, other nearby medical facilities report having additional capacity to perform more ophthalmic surgical procedures. ?So the question is,? says Mr. Cerceo, ?if we?re really looking for the best use of limited resources, why are we building more capacity when existing-area hospitals have the room to handle the University of Chicago?s surgical cases??

Some say the University of Chicago is phasing out its ophthalmic surgery department because it is no longer profitable, and that sending all cases to the ICO ASC is a better option. University representatives could not be reached for comment.

Says Mr. Paul, ?The ICO has zero expertise in running a surgery center. The University of Chicago is a highly respected health-care facility that?s been here for a long time. What makes the ICO think they can run a successful surgery center? They never revealed what expertise they have in making ophthalmic surgery profitable.?

A date won?t be set to begin construction on the ASC until the University of Chicago replaces its department of ophthalmology chairman, who?s retiring next year, says John Easton, director of media relations and public affairs. According to the ICO, candidates for the position will be required to agree to the optometry ASC project as a condition for being hired.

Says Pamela Lowe, OD, FAAO, president of the Illinois Optometric Association in Chicago, the ICO?s goal is not to take patients away from nearby hospitals. The college?s motive is to better serve patients and optometry students. ?Our goal is to take care of patients? needs,? she says. ?Our patients are indigent and don?t have the best care available to them. It?s my understanding that there?s much need for the ASC because patients don?t have the transportation they need to get from one location to another. They have to travel far [for ophthalmic surgery]. One of the hospitals [in the area] will be closing down in the near future, and the availability of surgical time is an issue at the nearby facilities. Patients can?t get in,? she says.

Additionally, students will be able to refer patients to ophthalmologists right under the same roof and observe the coordination of care between optometry and ophthalmology, says Dr. Lowe. ?It?s the perfect working model. The ICO is the number one eye-care facility for the patient population in that area. So it increases the quality of care for the patients,? she says.

That same line of thinking is what gave the State University of New York College of Optometry the desire to build an ambulatory surgery center at its New York City location. The facility was approved to begin construction in April 2002, but it has since been postponed because of insufficient financing until sometime in 2004.

Richard Weber, OD, vice president for clinical affairs and executive director of the SUNY College of Optometry says, ?The ASC will give patients complete comprehensive care and give us the ability to manage and follow them more closely and in a cost-effective manner. We want our patients to be in a patient-friendly environment and don?t want to see them leave our facility. Our surgeons will be here, so they won?t have to go to a different institution for eye surgery.?

But just as the Chicago-area hospitals and ophthalmologists oppose the idea of an optometry surgery center in their neighborhood, so do their colleagues in New York City.

?I couldn?t be more upset and disturbed about this,? says Paul N. Orloff, MD, attending physician at Manhattan Eye and Ear Hospital, and former president of the New York State Ophthalmological Society.

Dr. Orloff questions the numbers that the SUNY College of Optometry reported that doctors would commit to transferring to the ASC and erroneously claimed that the Medicaid population was being underserved by the area hospitals. ?They also exaggerated the need for additional operating-room space when the hospitals in the area can handle the volume,? he says.

The bottom line, he says, is that the ASC ?will give optometry students exposure to surgery, which furthers their agenda to eventually have optometrists perform surgery.?

 

[John_Doe]

www.sunyopt.edu/about/Accreditation_Report.pdf

Look at page 8, section XII, number 5

 

[OD2bGreg]

Holy old news batman

 

[John_Doe]

Some more articles regarding HB 2321 and VA policy - each of which have the potential to reshape the future ophthalmology for all of us:

1. http://www.revophth.com/index.asp?page=1_583.htm
To the editor:
I commend you on your recent article regarding Oklahoma optometrists? attempting to use their state legislature to expand their scope of practice to include surgery.

Optometrists say that the recently passed law that allows them to perform surgery is not an attempt to expand the scope of optometric practice. They say they are only interested in making sure they get paid for simple, non-invasive procedures such as punctal plugs or epilations.

It?s important to remember how this most recent controversy began. It began with Oklahoma optometrists asking to be paid for procedures that involved cutting the eyelids, not for simple, non-invasive procedures.

The problem, as the president of the Oklahoma Board of Optometric Examiners points out in the article, is that Oklahoma law doesn?t contain a specific definition of surgery. But instead of pursuing legislation that defines the type of simple procedures optometrists can perform, they opted for an even broader definition that allows them to perform any non-laser surgery as determined by the Oklahoma Board of Examiners in Optometry.

While the law is vague as to the types of surgery that optometrists can perform, it?s perfectly clear on who will make the final call, and it?s not the medical community: ?No agency, board or other entity of this state, other than the Board of Examiners in Optometry, will determine what constitutes the practice of optometry.? This truly breathtaking statement seems to imply that the optometry board does not even need the approval of the legislature or governor to define surgery, let alone the input of the only group trained to perform surgery and to make decisions regarding surgery?physicians.

The governor of Oklahoma has generously offered that he will work with all parties, including the medical community, to ensure that the final rules implementing the new law will neither expand nor contract the scope of optometric practice. While we applaud the governor?s decision to include the medical community?s input into the rule-making process, we still have no veto power. The power to decide who can provide ophthalmic surgery in Oklahoma still firmly remains in the hands of optometry?s Board of Examiners and politicians, not medical schools.

Once again, the scope of optometric practice in Oklahoma will be based upon optometrists? ability to lobby the legislature, rather than upon sound medical argument. And once again, Oklahoma residents and patients everywhere will be put at risk.

Sincerely,

David W. Parke II, MD
President and CEO
Dean McGee Eye Institute
Oklahoma City
Senior Secretary for Ophthalmic Practice American Academy of Ophthalmology.


2. http://www.revophth.com/index.asp?page=1_584.htm

VA Acts to Limit Optometric Surgery

In early August, the Veterans Health Administration announced a new policy that would require optometrists who perform laser surgery in VA hospitals to do so under the supervision of an ophthalmologist. What form this supervision will take is still being decided by the VA, however.

The announcement was prompted by the debate over the Veterans Eye Treatment Safety Act, currently in Congress, that would make it illegal for anyone but a licensed medical doctor or doctor of osteopathy to perform surgery in a VA facility. The legislation was in response to an outcry from the VETS Coalition, a group composed of the American Academy of Ophthalmology, congressional leaders and veteran service organizations. The coalition was disturbed by an incident of an Oklahoma-licensed optometrist performing laser eye surgery in a Kansas VA hospital, even though such surgery was outside the legal optometric scope of practice in Kansas.

?With all due credit to the VA, we may have taken a step in the right direction with the supervision requirement,? says H. Dunbar Hoskins Jr., MD, the AAO?s executive vice president. ?But, we don?t believe optometrists have the education, training or background to be doing intraocular eye surgery. Also, we don?t believe that veterans should be subjected on a national basis to the whims of a single state?s legislature ? We don?t understand the rationale behind this decision. However, the VA has the power and authority to make such a decision, and we?re now waiting to see how the supervision aspects roll out.?

On the other side of the debate, David Cockrell, OD, president of the Oklahoma state board of examiners in optometry, isn?t pleased with the decision because it establishes new limitations on optometric surgery where there once were none.

?I don?t think it?s a good policy,? says Dr. Cockrell. ?I don?t know of any other health-care providers that require supervision. It?s a restriction that we don?t think is necessary, and certainly hasn?t been proven to be necessary prior to this. To the best of my knowledge, there?s been no documented case of harm done to any veteran patient due to the optometric utilization of lasers.?
With regard to the issue of credentialing in Oklahoma allowing optometrists to perform laser surgery in any state?s VA hospitals, Dr. Cockrell says there are numerous precedents for such a situation.

?In the federal system, as ophthalmology is acutely aware, whatever your license happens to be, whether it?s MD, OD or DDS, each practitioner is allowed to practice to the extent that his license allows,? he says. ?I?d ask you to apply that same question to dentistry [in the VA], because there are many different dental statutes that allow different procedures in different states, but I don?t hear that question being asked by medicine as it concerns dentistry ? My concern is that I hear medicine saying that it wants a national law that applies to optometry only.?

Dr. Hoskins has also expressed a concern that the new policy establishes two standards of care, one in which the patient undergoes surgery by an ophthalmic surgeon, and another in which he undergoes surgery by someone with ostensibly less experience, the optometrist. In a written response to this and other issues prepared by the VA for Review, the agency says, ?For performance of therapeutic laser eye procedures by optometrists at VA medical facilities, there will be ophthalmologist supervision to ensure one standard of care.?

This prompts the question: If you were a patient, would you rather have the presumably more-experienced surgeon just supervise or actually perform your laser procedure?

The VA responds, ?The VA credentialing and privileging process ensures that all VA health care providers?including optometrists and ophthalmologists?are well-qualified to perform in their respective roles. Veterans are fully informed and involved in decisions concerning their care. Veterans undergoing surgery are provided with the names and roles of the practitioners performing or supervising the procedure. When patients make specific requests regarding the practitioners assigned to their care, VA makes an effort to accommodate them.?

The big question remains, how will the supervision be structured? The VA has formed a work group to ?develop recommendations and an implementation plan? to meet the requirements of the policy directive governing laser eye procedures, specifically the ophthalmologist-supervision requirement. Members of the work group include James C. Orcutt, MD, the VA?s national clinical program director for ophthalmology, and John C. Townsend, OD, the clinical program director for optometry. According to the VA?s statement, ?The group?s efforts are under way.?

 

[John_Doe]

Excert from a 1994 PAC solicitation letter from the OK ODs in Action:

"We can eliminate ophthalmology from this state and prove to the nation that optometry can provide total medical and surgical treatment for the eye . . . We honestly believe that optometry can provide most (if not all) surgical eye care by 2000 . . . Ophthalmology is so weak politically that we see smooth sailing to the control of eye care in this state . . . In order to place our people in key decision making posiitions, we need your support now. Fortunately, ophthalmology is well behind us. As usual they're too busy making the big bucks to think past the first base. Our sources tell us they've done nothing at the state level regarding legislation. We'll trounce them."
AND THEY DID

FACT:
Ten years later wee see the passage of OK law HB2321, which authorizes the board of mainly optometrists to decide what types of surgeries optometrists can perforn on the eye and face. The fact that optometrists can now perform surgery in Oklahoma should come as no surprise (and for that matter laser in the VAHs) - the ophthalmologists there were certainly forwarned - and probably gave squat to their PACs - there are 49 states to go and momentum not in our favor.

This will definitely affect the future of ophthalmology.

Do we ever get to hear what the patients want?
----------
However the Todd Wright in OK would have you think otherwise - this from OCT 2004

Wed October 6, 2004


Scope-of-practice rift over eye surgery flares

By Jim Killackey and Carmel Perez Snyder
Staff Writers

Allowing optometrists to perform eye surgery lowers Oklahoma's standard of health care and places patients at risk, physicians and ophthalmologists said Tuesday at the state Capitol.

Optometrists said such concerns and criticism are baseless.

The scope-of-practice rift erupted again at the Tuesday news conference, where eye doctors pleaded with Gov. Brad Henry to reject rules they believe will allow optometrists to perform eye surgeries that include incisions.

Representatives from the Oklahoma Medical Association, American Medical Association, Oklahoma Osteopathic Association, Oklahoma Academy of Ophthalmology and American Academy of Ophthalmology spoke with one voice in opposition to rules passed Monday by the Oklahoma Board of Examiners in Optometry.

The rules would allow optometrists to perform eye surgery with a scalpel. The move came as a result of House Bill 2321, passed this year by the Legislature.

"Oklahoma is the only state in the nation that risks its citizens' health and safety by allowing nonphysicians to perform eye surgery," AMA trustee Dr. William A. Hazel Jr. said Tuesday.

Ophthalmologists consider eye surgery inappropriate for optometrists. Optometrists said that for years they've been able to perform minor procedures, such as removing eyelid growths, cysts, sties and lashes.

There are about 80 ophthalmologists in Oklahoma and about 590 optometrists.

Dr. Todd Wright, president of the Oklahoma Association of Optometric Physicians, said the new law "in no way amplifies, expands, increases or deletes our current scope of practice. Any insinuation that it does is absolutely false."

"Oklahoma optometric physicians haven't performed and aren't seeking to perform cataract surgery, cosmetic eyelid surgery, retinal surgery or nonlaser corneal surgery," said Wright, of Edmond.

The governor has 45 days to approve or disapprove the emergency rules passed by the optometry board.
http://newsok.com/article/1332596/?template=news/main

 

[OzDDS]

As a person very familiar with Ophthalmology, I would be much more cautious choosing this profession in the current political environment given the relentless lobbying effort of optometry (which even begins with thier training) to gain the surgical priv. of Ophthalmology. This has gone on for years, but the recent two defeats (listed below) may be the straws that break the camels back. What do you think?

I assure you that 10-20 years ago people would say that it was crazy to think something like the above would pass - now it has and this is only the beginning.

Would the US insurance and medicare be able to pay optemtrist less for the same surgeries?

http://forums.studentdoctor.net/showthread.php?t=153483

 

[Andrew_Doan]

Would the US insurance and medicare be able to pay optemtrist less for the same surgeries?

http://forums.studentdoctor.net/showthread.php?t=153483

Currently no. For ophthalmic examinations, the billing codes are the same. This is why, according to Jenny W., optometrists are using the term optometric "physicians".

 

[Visioncam]

The use of the term "optometric physician" is deceptive. This practice should end. It cheats the public. It also eliminates the term to specify what an ophthalmologist is. The OD's stole the word "doctor" and now they are stealing the word "physician". The American Academy of Ophthalmologists uses the term "Eye M.D." but only because they were forced into a hole. The term "Eye M.D. or D.O" would be too much of a mouthful.

To avoid confusion, optometrists should get the degree BOptom like they do in Australia. They need not fear. They could still wear a white coat and patients would still go to them.

Oral surgeons use the same codes as physicians. Dentist don't call themselves "dental physicians". Nurse anesthetists don't call themselves "anesthetist physicians."

 

[JennyW]

Currently no. For ophthalmic examinations, the billing codes are the same. This is why, according to Jenny W., optometrists are using the term optometric "physicians".

This is not exactly true. Medicare does pay ODs and OMDs the same fee for the same procedure, however most private insurers do NOT. But this is NOT why the term optometric physician came about.

In the past, many private insurers (BCBS, Aetna, Cigna etc etc etc) would NOT allow panel participation by "non-physician" providers. It doesn't make much sense that a pediatrician can see a patient with conjunctivits, prescribe polytrim and get reimbursed for it but an OD can't, simply because the OD is a "non-physician" provider.

Once the moniker "optometic physician" was adopted in some states, panel participation immediately became available to ODs.

This was the ONLY reason it was adopted. Not to deceive the public, not to expand scope of practice or any of that crap. It was done solely as a means of obtaining access to 3rd party panels.

Jenny

 

[JennyW]

The use of the term "optometric physician" is deceptive. This practice should end. It cheats the public. It also eliminates the term to specify what an ophthalmologist is. The OD's stole the word "doctor" and now they are stealing the word "physician". The American Academy of Ophthalmologists uses the term "Eye M.D." but only because they were forced into a hole. The term "Eye M.D. or D.O" would be too much of a mouthful.

To avoid confusion, optometrists should get the degree BOptom like they do in Australia. They need not fear. They could still wear a white coat and patients would still go to them.

Oral surgeons use the same codes as physicians. Dentist don't call themselves "dental physicians". Nurse anesthetists don't call themselves "anesthetist physicians."

Maybe the dentists should be given the degree BDent or BTeeth then.

See my previous post as to why the term optometric physician came about.

Jenny

 

[OzDDS]

Maybe the dentists should be given the degree BDent or BTeeth then.

See my previous post as to why the term optometric physician came about.

Jenny

They do use BDent! (BDent or BDS) That is the name of the degree you recieve when you graduate from dental school in the UK or Australia.
If you graduate from medical school in the UK or Australia you would also recieve a bachelor of medicine...(BMed, MBBS, or MBCHB).. but these bachelor degrees are equivilent to MD and DDS/DMD in the US. When a doctor from the UK comes to the US they are allowed to be called "MD" because they are viewed as the same degree.


http://forums.studentdoctor.net/showthread.php?t=149643
http://forums.studentdoctor.net/showthread.php?t=33413&highlight=mbbs
http://forums.studentdoctor.net/showthread.php?t=81416&highlight=mbbs

 

[OzDDS]

also Anesthesiologists are referred to as Anesthatists in the UK and Australia.

 

[John_Doe]

http://www.revoptom.com/index.asp?page=2_1255.htm
Optometric Council on Refractive Technology To Hold Its First Meeting

The Optometric Council on Refractive Technology (OCRT) will hold its first annual meeting and educational seminar on Wednesday, December 8, 2004, at the Tampa Convention Center prior to the American Academy of Optometry Meeting.

The OCRT was organized in February 2002, when 13 optometrists from across the country met to discuss optometry?s role in refractive procedures that alter the structure of the eye to correct refractive errors (refractive technology). OCRT has since incorporated as a 501C3 not-for-profit educational corporation and affiliated with the American Academy of Optometry.

The OCRT estimates that as many as 400 optometrists will attend the meeting. Says Louis Phillips, O.D., president of OCRT: ?The recent decisions on the part of the Academy of Ophthalmology and ASCRS demonstrate even more so the need for this organization.?
The program will include presentations about the latest technology and intraocular procedures vs. corneal procedures, and a debate on controversial topics such as comanagement and ***optometric ownership of laser centers. It will offer a uniquely optometric perspective on the functional rehabilitation of the human visual system through refractive technology.

The meeting will include a full day of interactive education, including breakfast, lunch and an evening social.

For answers to questions or to obtain a registration form for the meeting, e-mail Dr. Phillips at [email protected] or call (724) 933-5588.

 

[John_Doe]

http://www.optometric.com/article.aspx?article=71171
o.d. to o.d.
How to Respond to Organized Ophthalmology
Ophthalmology has banned us from their meetings and has portrayed optometry in a negative light. But rather than complain, it's optometry's turn to go on the offensive.
BY WALTER D. WEST, O.D., F.A.A.O., Chief Optometric Editor

Over the past several months, we've seen ophthalmology ban us, as optometrists, from attending courses at the American Academy of Ophthalmology's meeting. We've also seen the American Society of Cataract and Refractive Surgeons ban us from its meeting. And we've seen ophthalmologists present "studies" that seem to show optometry as "over-prescribers."

All of this posturing has spawned numerous ophthalmologist-penned editorials that clearly show ophthalmology's true colors. As these events developed, I have, for the most part, sat back and watched. I'm surprised, amazed and bewildered, not by the ophthalmologists' actions, but by the fact that optometrists were surprised by it all. Perhaps the recent expansion of optometry's scope of practice gave many optometrists the sense that things have changed. In many respects they have, but it's clear that ophthalmologists continue to view optometrists more as a threat than as colleagues.

Actions speak louder

So what's the appropriate response? I suggest that we not idly sit back and complain about how inappropriate ophthalmology's actions have been, how misguided its positions might be or how inaccurate its perceptions of our prescribing habits appear.

Rather, I suggest that now is the time for us to go on the offensive -- not by misrepresenting allegations about what optometry is, has been or could be -- but by continuing to move optometry in the direction that we've chosen. We should continue to expand the scope of optometric practice through education. We must improve, to an even greater degree, our ability to provide primary care in addition to the core competencies that we possess in the areas of comprehensive eye exams, the prescribing of spectacles and contact lenses.

Addition, not replacement

It's important to recognize that I say "in addition to" rather than "instead of." It has been shown time and time again that the patient who depends on our core services today will ultimately become the patient who depends on our primary care services tomorrow. In fact, most patients don't really use primary care services (or to any great degree, medically related eye care) until the age of 40 and beyond.

Our ability to gain new patients and educate them as to our ability to provide comprehensive eye care, even on vision-related patient visits, will prove to be seeds well-planted and from them we will reap great benefits in the future of our practices.

Contribute to your success

Simultaneously, we must all --that is, every one of us -- do our share in contributing to state and national optometric political action funds. These funds put ourselves in a posture to defend what we have already gained in scope of practice. Just as important, optometric organizations use the funds to advance our scope of practice even further.

So if you're wishing that someone would do something about ophthalmology, then realizes that it starts with you and me, in our own offices with our own patients and with our own checkbooks. Are you willing to do something?

 

[John_Doe]

Henry approves optometry rule

ASSOCIATED PRESS

Updated: October 30, 2004 6:52 AM

Governor Brad Henry has signed an emergency rule that would limit what surgical procedures an optometrists can do.

Ophthalmologists, medical doctors who specialize in the eye had asked Henry to reject a rule adopted by optometry board.

That rule allowed optometrists, who aren't physicians, to cut eyelids and do other surgery.

Optometrists say the new rule only allowed them to perform procedures they have been doing for more than 20 years.

Ophthalmologists say that those procedures amounted to surgery and never had been authorized in state law.
------------------------
"Oklahoma no longer appears to be an abberation . . . . If you are not involved in the political system, it is assumed that you do not care. Be involved with your state and national academies, or optometry will define ophthalmology." (Lanciano R, crstoday).

If you think what is happening in Oklahoma does not foreshadow what will occur in your state, then think again.

The future of ophthalmology and patient eye care is in the process of potentially tremendous transformation. I would be concerned if I were thinking of entering this profession - and even more so if already in the early years of training/practice.

 

[smiegal]

If you think what is happening in Oklahoma does not foreshadow what will occur in your state, then think again.

The future of ophthalmology and patient eye care is in the process of tremendous transformation. I would be concerned if I were thinking of entering this profession - and even more so if already in the early years of training/practice.

[/QUOTE]


I love the repetitive doomsday messages from this guy. "Oooh, here we come... We're numerous and well-organized! I would avoid Ophthalmology if I were you! Oh, and did you see the disgusting attempts by opticians to expand their scope!"

Do you think that you'll help decrease the quality of Oph applicants, or what? Or is this an ode of good will to prospective future Ophthalmologists that they don't get trod upon by your ilk.

Anyhoo, thanks for posting the OD to OD memos, at least. It's nice to have solid evidence of OD intentions to show non-MD's that the "We're just trying to protect what we already have" argument by OD's in OK is bogus.

 

[John_Doe]

[/I]

I love the repetitive doomsday messages from this guy. "Oooh, here we come... We're numerous and well-organized! I would avoid Ophthalmology if I were you! Oh, and did you see the disgusting attempts by opticians to expand their scope!"

Do you think that you'll help decrease the quality of Oph applicants, or what? Or is this an ode of good will to prospective future Ophthalmologists that they don't get trod upon by your ilk.

Anyhoo, thanks for posting the OD to OD memos, at least. It's nice to have solid evidence of OD intentions to show non-MD's that the "We're just trying to protect what we already have" argument by OD's in OK is bogus.[/QUOTE]
-----------------------------------------

Ophthalmology is a great profession, and I am happy that I am an ophthalmologist (being an optometrist or optician are great professions as well)- just really think some of the current issues are important for this forum.

 

[John_Doe]

Academy Celebrates State Legislative Victories in 2004

September 29, 2004

WASHINGTON?The American Academy of Ophthalmology celebrated successes in 2004 as it advanced the cause for quality eye care in state legislatures.

Ophthalmology scored nine state legislative and regulatory scope-of-practice victories this year in Puerto Rico, New York, Massachusetts, Florida, Alaska, Mississippi, Maryland, Louisiana, and Tennessee. Most significant was the Puerto Rico Ophthalmological Society?s defeat of a bill that would have allowed the broadest optometric scope of practice in the U.S. This bill allowed optometric surgical privileges and prescribing authority for all systemic drugs.

?We attribute our success in these state battles to state ophthalmological society leadership, an increase in our contributions to state society political action committees, support by the Academy?s Surgical Scope Fund and an upsurge in the involvement of young ophthalmologists in the state political process,? said Cynthia Bradford, MD, secretary for State Affairs. ?In the seven years since the optometry lobby forced a laser surgery bill through the Oklahoma state legislature, no other state legislature has authorized optometrists to perform surgery. Ophthalmologists have taken time to educate state legislators about the importance of preserving safe eye surgery, which is a key factor in our success.?

Since the Oklahoma laser bill passed in the late 1990s, the Academy has helped 14 states (Alaska, California, Florida, Iowa, Massachusetts, Minnesota, Mississippi, New Jersey, North Carolina, South Carolina, Puerto Rico, Texas, Vermont, and Washington) to reject optometric surgery language. In addition, during this time period, the Academy and state societies in Arizona, Montana, Texas, and Washington worked with legislators to pass legislation clarifying that optometrists are not authorized to perform laser surgery. These statutes represent major
victories for patient quality care and safety. . . .

 

[Mirror Form]

Academy Celebrates State Legislative Victories in 2004

September 29, 2004

WASHINGTON?The American Academy of Ophthalmology celebrated successes in 2004 as it advanced the cause for quality eye care in state legislatures.

Ophthalmology scored nine state legislative and regulatory scope-of-practice victories this year in Puerto Rico, New York, Massachusetts, Florida, Alaska, Mississippi, Maryland, Louisiana, and Tennessee. Most significant was the Puerto Rico Ophthalmological Society?s defeat of a bill that would have allowed the broadest optometric scope of practice in the U.S. This bill allowed optometric surgical privileges and prescribing authority for all systemic drugs.

?We attribute our success in these state battles to state ophthalmological society leadership, an increase in our contributions to state society political action committees, support by the Academy?s Surgical Scope Fund and an upsurge in the involvement of young ophthalmologists in the state political process,? said Cynthia Bradford, MD, secretary for State Affairs. ?In the seven years since the optometry lobby forced a laser surgery bill through the Oklahoma state legislature, no other state legislature has authorized optometrists to perform surgery. Ophthalmologists have taken time to educate state legislators about the importance of preserving safe eye surgery, which is a key factor in our success.?

Since the Oklahoma laser bill passed in the late 1990s, the Academy has helped 14 states (Alaska, California, Florida, Iowa, Massachusetts, Minnesota, Mississippi, New Jersey, North Carolina, South Carolina, Puerto Rico, Texas, Vermont, and Washington) to reject optometric surgery language. In addition, during this time period, the Academy and state societies in Arizona, Montana, Texas, and Washington worked with legislators to pass legislation clarifying that optometrists are not authorized to perform laser surgery. These statutes represent major
victories for patient quality care and safety. . . .

It's always nice to hear some good news, thanks!

 

[John_Doe]

Taking a Stand for Ophthalmology

By Stephen Barlas

Ophthalmology is at a critical juncture. Optometrists have won full surgical privileges in Oklahoma and limited privileges within the VA. Fortunately, there is still time to reverse these decisions, and ophthalmology?s leaders are working furiously to ensure surgery by surgeons. The greatest hope for our patients and profession? That all Academy members realize that their input is needed.

When his cell phone rang at 6 p.m. on June 23, Pat Eddington was already a man in a hurry. The lobbyist for the Academy was on the verge of walking out of his office to attend a political fundraiser after a day of pounding the hallways of the three U.S. Senate office buildings in an effort to line up support for a crucial vote that evening on the Senate floor. Sen. Peter Fitzgerald (D-Ill.) would be offering an Academy-sought amendment to a defense bill allowing only a licensed medical doctor or licensed doctor of osteopathy to perform eye surgery at a Department of Veterans Affairs facility. The amendment was based on the ?Veterans Eye Treatment Safety (VETS) Act of 2003? introduced in November 2003 by Rep. John Sullivan (R-Okla.) in response to the granting of surgical privileges to an optometrist at a VA hospital in Kansas.

But an aide to Sen. Fitzgerald was on the other end of the line. He told Mr. Eddington that Sen. Carl Levin (D-Mich.) had placed a ?hold? on the Fitzgerald amendment. That meant it could not be brought up for a noncontroversial, unanimous consent vote. An hour later, the same aide called again. Now a Republican senator was raising objections. Fortunately, Cathy Cohen, Academy vice president of Government Affairs, happened to be having dinner with that senator and others at just that moment. Mr. Eddington, now at dinner at a downtown D.C. restaurant, called Ms. Cohen. She talked with the senator, and he agreed to release his hold. By 9 p.m., all Senate Republican opposition had been erased. Still, there was Sen. Levin?and now, Sen. Barbara Boxer was tossing legislative roadblocks in front of the Fitzgerald amendment.

With those two Democrats refusing to allow the Academy-sponsored bill to come up for a vote, the Academy decided not to force the issue that evening. A controversial floor fight was not in the best interests of ophthalmologists. Nor was it worth jeopardizing the significant political headway the Academy had made during the 108th Congress, gains that would serve as momentum for new efforts to blunt the aggressive drive by optometrists to become de facto ophthalmologists. Instead, on July 22, the five senator sponsors of the Fitzgerald amendment opened a second legislative front in the battle for ?Surgery by Surgeons? through the introduction of a stand-alone Senate version of the VETS Act.

Optometry?s Maneuvers
Optometry?s efforts to achieve medical privileges have been going on for decades. State legislatures have widened optometry?s scope of practice bit-by-bit until services like prescribing medication seem like an optometric right, not a patient wrong. Then in a 1998 vote that caused patient safety advocates everywhere to do a double take, the Oklahoma legislature allowed optometrists to perform anterior segment laser surgeries. But the latest instance of scope of practice expansion?which occasioned the Fitzgerald amendment?was unprecedented: It took Oklahoma state law national.

Using that 1998 law as a lever, an Oklahoma optometrist at the Robert J. Dole Veterans Affairs Medical Center in Wichita, Kan., convinced the facility medical director in 2003 to acquire an ophthalmic laser and ?privilege? her for anterior segment laser surgery and lid surgery. While it turns out that she is one of at least three optometrists able to perform laser surgery in the VA, her high-profile case may go a long way toward smoothing the way for other Oklahoma-licensed optometrists to conduct laser surgery at VA facilities around the country.

Then in 2004, back in the state of Oklahoma, optometrists pushed the envelope, arguing that the 1998 law allows them to perform noncosmetic lid surgery because that law only rules out laser surgery on the retina, LASIK and cosmetic lid surgery. However, on April 6, 2004, Oklahoma Attorney General W. A. Drew Edmondson disagreed with that interpretation. He said the Optometry Board would need ?statutory authority? from the Oklahoma legislature before it could certify optometrists to do more than the PRK and anterior segment laser procedures endorsed by the 1998 law.

That?s when the Oklahoma legislature took a second step in that very wrong direction, passing a second bill in May 2004 specifically endorsing ?surgery? as an optometric right. What?s more, it boldly stated that the Oklahoma Board of Examiners in Optometry, and only that Board (not the state medical board, for example), was responsible for defining optometric scope of practice. Those provisions were added to a pharmacy bill while it was in conference between the Oklahoma House and Senate, the legislative equivalent of ?the dead of night.? There were no hearings on the optometric provisions in HB 2321. ?The new Oklahoma law is the most egregious example yet of optometry using state legislatures to expand their scope of practice,? stated H. Dunbar Hoskins Jr., MD, executive vice president of the Academy.

After the bill?s passage, David Cockrell, OD, FAAO, president of the Board of Examiners in Optometry, said in Review of Optometry that the bill did not expand current optometric scope of practice. Rather it was necessary, after the attorney general?s April judgment, to clarify that optometrists can perform epilation and punctal plugs, two procedures classified as surgery by the American Medical Association?s CPT code.1

Oklahoma Ophthalmology?s Position
Ann A. Warn, MD, MBA, president of the Oklahoma Academy of Ophthalmology, doesn?t have a problem with optometrists doing epilation or punctal plugs. Nor do most ophthalmologists. But if that is the extent of the scope expansion desired by Oklahoma optometrists, then she wonders why didn?t they have those two procedures, and only those two procedures, written into HB 2321? She said, ?It?s really quite simple: Surgery should be performed by surgeons who graduate from a medical or osteopathic school, complete a one-year hospital internship and then complete a three-year residency specialty in eye disease and surgery.?

Patient safety motivates ophthalmology?s opposition to optometric surgery, not any economic threat. ?This is not a financial issue,? said Dr. Warn. ?We are concerned about the quality of care for the citizens of Oklahoma.?

In fact, said Cynthia A. Bradford, MD, secretary of State Governmental Affairs for the Academy and an Oklahoma ophthalmologist herself, her practice has not been impacted at all by the 1998 law that sanctioned optometrists performing PRK laser surgery, YAG capsulotomies, argon laser trabeculotomies for glaucoma and laser peripheral iridotomies for narrow-angle or angle-closure glaucoma.

Dr. Warn agreed that her practice hasn?t been hurt, either, because of the small number of optometrists doing those laser procedures, and the fact that most optometrists exercising their 1998 privileges are concentrated in Oklahoma City and Tulsa, even though optometrists argued for laser surgery rights based on the need of rural patients.

Medicine Comes Together
The patient safety concerns voiced by ophthalmologists stem from the diametric differences in training between optometrists and ophthalmologists. ?Optometrists want to set up a parallel profession without having to get the medical training we get,? said Dr. Bradford. That was the refrain echoing in Oklahoma City on July 11 during a special session called by the Oklahoma Academy of Ophthalmology. The meeting took place while advertisements paid for by the American Academy of Ophthalmology filled the radio airwaves. One ad shed light on the difference in training between optometrists and ophthalmologists. The other asked why Oklahoma is the only state in the union to give optometrists the right to do surgery.

Allan D. Jensen, MD, president of the Academy, flew in from Baltimore for the Oklahoma City meeting. ?Oklahoma ophthalmologists recognize the Academy is very serious about this because 12 members of the board of trustees attended that meeting,? he said. Herman I. Abromowitz, MD, an American Medical Association trustee, was also there. The AMA is concerned about the impact of the Oklahoma 1998 and 2004 laws in a broader sense, because they are just another example of nonphysicians reaching for physician practice prerogative. For example, in April the Louisiana legislature passed a bill in near-record time allowing psychologists to prescribe drugs. ?Proponents of this bill are putting patients? lives at risk,? said Marcia K. Goin, MD, president of the American Psychiatric Association. ?Psychologists are not medical doctors, and, under the bill, they would not be required to get the training necessary to safely prescribe potent medications.? Dr. Abromowitz alluded to this ?parallel profession? epidemic at the July 11 summit. ?Since the debate concerning the expansion of the practice of nonphysicians implicates vital issues of state public health and safety, it affects all physicians and their patients,? he said. ?As such, whether it?s optometrists wanting to perform surgery in Oklahoma or psychologists seeking to prescribe psychotropic medications in New Mexico and Louisiana, the AMA believes it must be strong in its conviction that unacceptable expansions into the practice of medicine must be prevented.?

The Oklahoma City meeting reinforced the Academy?s commitment to the Surgery by Surgeons campaign that opposes efforts by any state legislature to expand optometric scope to include optometric surgical privileges.

 

[John_Doe]

A Look at OD Training
Are optometrists in Oklahoma adequately trained for noncosmetic lid surgery? What about for laser surgeries such as YAG capsulotomies, argon laser trabeculotomies for glaucoma and laser peripheral iridotomies for narrow-angle or angle-closure glaucoma?

Northeastern State University, the only college of optometry in Oklahoma, has included use and theory of lasers in its curriculum since 1988, according to George Foster, OD, dean of the school. In the current school year at Northeastern, for example, the 26 fourth-year students, 12 residents and 22 faculty will perform ?several thousand? surgical procedures, which include anterior segment lasers and minor office-based procedures. He declined to say exactly how much surgical experience each student receives nor how many laser surgeries a student might perform during the four-year curriculum.

For practicing Oklahoma optometrists who wished to become certified in laser surgery last spring, Northeastern and TLC Laser Eye Centers offered a two-day course. The marketing brochure stated that training would include ?14.5 hours didactic, four hours clinical with written exam, FDA laser course with wet lab for either Visx S4 Custom Vue or LadarVision Custom Cornea.? In addition, ?to complete the Oklahoma certification process . . . doctors must perform four proctored LVC [laser vision correction] cases within one year of completion.? The course prerequisites included completion of the Northeastern course ?Laser Therapy for the Anterior Segment,? which includes nine didactic and seven clinical hours.2

It should be noted that eye patients rate ophthalmologists more highly on quality of care than they do optometrists. In October 2003, as the Oklahoma laser surgery issue was morphing into a VA issue, the Academy commissioned a survey by a company called QEV Analytics. QEV queried 1,000 veterans across the country on a variety of issues. Sixty percent of patients who had been treated by an ophthalmologist rated their treatment as excellent. Optometrists got an excellent ranking from only 40 percent of their patients. That survey also underlined the confusion in the public?s mind about the difference in training and education between the two professions. Twenty-nine percent of the veterans queried said they believed optometrists are medical doctors; another 32 percent were unsure. Only 39 percent correctly stated that optometrists are not trained as medical doctors. Last, 95 percent of the veterans said it is very important to have a medical doctor specializing in eye care do eye surgery.

The Academy, in its July radio campaign in Oklahoma, exposed the mistaken belief that optometrists are, or may be, medical doctors, and therefore as qualified as ophthalmologists to do laser surgery and noncosmetic lid surgery.

Oklahoma: A Slippery Slope
?Ophthalmologists may have some honest differences of opinion among themselves on whether optometrists should have the authority to prescribe this or that drug,? said Bob Palmer, director of State Governmental Affairs for the Academy. ?But there is no question that surgical privileges are a defining issue for the profession. In final consideration, it is the patient that loses if optometric surgery laws like Oklahoma?s are left unchallenged.

______________________________
1 Murphy, J. Review of Optometry 2004;141(6):6, 10.
2 ?Laser Vision Correction Presented by: NSU Oklahoma College of Optometry and TLC Laser Eye Centers April 2?4, 2004.?

______________________________
Three Ways to Take Action

Contribute to the Scope Fund as generously as possible by going to www.aao.org and clicking Government Affairs, then Surgical Scope Fund. From there, you can either contribute online or download a form to fax or mail with your donation.

Contact your federal and state legislators and the U.S. president?even if the issue isn?t forefront for your area right now. Send a letter to President Bush on the issue of Surgery by Surgeons. Do this from www.aao.org by clicking Government Affairs, then Action Center. To get contact information for your state and federal representatives, hit the Elected Officials tab.

Write a letter to the editor of your local newspaper. From the Action Center, hit the Media Guide tab, click your state and pull up links to all the local newspapers. Choose one, and write to the editor of your choice. Send your letter as an email or a snail mail.

______________________________
Why You Must Take Action Now

Since the passage of the 1998 Oklahoma surgical statute, the optometric lobby has pushed surgical expansion proposals in legislatures across the country. In each case, ophthalmologists have united with their medical and osteopathic colleagues to educate legislators about patient risks associated with optometric surgical expansion. As a result, ophthalmology has had victories in 18 states, and optometric surgery has not expanded past the Oklahoma borders. But, as long as optometrists continue to successfully push their agenda in the Oklahoma legislature, patient care not only in Oklahoma but also in every state is at risk. This is why all ophthalmologists must join the battle.

Optometry Is a Formidable Foe for Two Major Reasons
Dollars. An overwhelming majority of optometrists donate to the American Optometric Association?s national political action committee and to their state PACs, and that money is used to help elect friends of optometry into the state and federal legislatures. By comparison, less than half of all ophthalmologists donate to their state PAC and to OphthPAC.

Numbers. In Oklahoma, for example, there are 400-plus optometrists vs. about 160 ophthalmologists. ODs have made the best of this numerical advantage, whereas many Oklahoma state senators and assembly members have no ophthalmologists as friends or foot soldiers in their campaigns.

But ophthalmologists have exacerbated that numerical deficit by sitting on the sidelines. Here are six commons arguments they give for not getting involved, and reasons why they should.

1. Optometrists give me referrals. I don?t want to jeopardize this relationship.

Take action because: If optometrists get surgical privileges, there won?t be a need for them to refer patients to ophthalmologists.

2. I have not comanaged with optometrists, so I am not at all responsible for allowing them to make incursions into ophthalmology. Let the ophthalmologists who caused the problem fix it.

Take action because: Ophthalmologists are all in this together. And in the end, it is our responsibility as physicians to make sure patients do not suffer subpar care.

3. I pay Academy membership dues. They should handle this.

Take action because: The Academy has established the Surgery by Surgeons campaign to respond to this threat. But when it gets down to the nuts and bolts of winning over state legislatures, an individual ophthalmologist?s action or inaction will make the difference.

4. Scope of practice incursions haven?t been bad in my state. This doesn?t affect me.

Take action because: If it hasn?t happened in your state this year, it will happen next year or the year after.
5. We?ve adapted to incursions into our practices over the last several decades, why not this, too?

Take action because: This time, patients are put at significant risk.

6. If patients get bad eye surgery from ODs, there will be malpractice suits and repeal of legislation. Let the market play it out.

Take action because: The market may not take care of the problem. Even if it does, patients may suffer harm in the meanwhile.

 

[HOLLYWOOD]

If reimbursement rates keep going down we will all be doing something else.We should all get together and fight the ins. companies.They're the real threat to our professions.

 

[HOLLYWOOD]

I'd like to know everone's feelings on dentists prescribing oral medications. I would also like to know how a P.A. can do an entire PE and then write a prescription for an oral medication. And I don't want to read that the Dr. supervises the P.A. because he was'nt in the office at the time of the exam.

 

[HOLLYWOOD]

I agree with Geddy. Most people outside of medicine do not understand the difficulty of matching for a competitive residency like ophthalmology. If you think it's difficult to get into medical school, the ophthalmology match is several fold tougher. In addition, you're also competing with the top quartile of all medical students when you enter the ophthalmology match.[/QUOT

It is not as difficult to get a ophthalmology residency as it used to be, foreign medical grads and D.O.'s are getting them. OMD'S are not making the money they was did so they are choosing more lucrative specialties.

 

[Mirror Form]

It is not as difficult to get a ophthalmology residency as it used to be, foreign medical grads and D.O.'s are getting them. OMD'S are not making the money they was did so they are choosing more lucrative specialties.

Actually, it's very rare for foreign grads or D.O.'s to match into allopathic ophtho positions. The only foreign grads that even have a chance are ones that have already completed an ophthalmology residency in their own country. And even then they only have a very tiny chance at the least competitive programs.

 

[HOLLYWOOD]

Retinamark,

In the USA, almost all code blues ougside a hospital building, that means across the street from the hospital almost always requires paramedic intervention. I witnessed recently in a clinic two code blues in the last 3 months and in each instance, paramedics arrived within 3 minutes and provided life support even though 3 physicians and 3 RNs were present.

I believe that your admonition would be more applicable outside the USA or within the hospital itself. But in most circumstances, in a doctor's office, in a clinic that is separated geographically from the hospital, a crash cart and crash cart team would not necessarily alter the outcome (if these offfices or buildings had one).

Richard Hom, OD, FAAO
San Mateo, CA

I work with 4 omd's and 4 od's we had a pt. pass out and you know what we did ? we called 911.

 

[HOLLYWOOD]

To the cowboy wanna-be surgeon optoms, we can ask the question:

"Would you want your grandmother to have surgery by someone who has done 4 years of training & can occasionally get it right, or someone who has done 10-15 years of training to prepare themselves for every possible scenario?"

Why should someone's grandma suffer just because some optoms lacking insight & morals want to earn more money without doing the proper training?

I know a ophthalmologist who considers himself an oculoplastics specialist. There is only one problem he never did a fellowship in oculoplastics. Do you think he should be doing these procedures? Would you let him work on you ? He want's to take a wet lab and do lipo of the face. Soon he'll be doing breast implants, but he is a medical doctor he can do what ever he want's he is not a danger to pt's b/c of that md degree.

 

[Andrew_Doan]

I know a ophthalmologist who considers himself an oculoplastics specialist. There is only one problem he never did a fellowship in oculoplastics. Do you think he should be doing these procedures? Would you let him work on you ? He want's to take a wet lab and do lipo of the face. Soon he'll be doing breast implants, but he is a medical doctor he can do what ever he want's he is not a danger to pt's b/c of that md degree.

Oculoplastic procedures range from blephs, ptosis repairs, slings, flaps, enucleation, eyelid repair/reconstruction (simple to complex) and facial cosmetics. You listed one extreme in regards to the lipo of the face and breast augmentation.

General ophthalmologists ARE trained to perform blephs, ptosis repairs, eyelid repair/reconstruction, and enculeations. For instance, after finishing my training at Iowa, I will have performed over 100 oculoplastic surgeries.

Those who choose to complete an oculoplastics fellowship will be able to perform more complex surgeries.

For the common variety surgeries, I would let the physician above operate on me.

Your example is a poor comparison to the optometrists in Oklahoma wanting to do lid surgeries. How many optometrists have even worked with 7-0 Vicryl suture on the face? I know this is not part of your training.

 

[HOLLYWOOD]

Oculoplastic procedures range from blephs, ptosis repairs, slings, flaps, enucleation, eyelid repair/reconstruction (simple to complex) and facial cosmetics. You listed one extreme in regards to the lipo of the face and breast augmentation.

General ophthalmologists ARE trained to perform blephs, ptosis repairs, eyelid repair/reconstruction, and enculeations. For instance, after finishing my training at Iowa, I will have performed over 100 oculoplastic surgeries.

Those who choose to complete an oculoplastics fellowship will be able to perform more complex surgeries.

For the common variety surgeries, I would let the physician above operate on me.

Your example is a poor comparison to the optometrists in Oklahoma wanting to do lid surgeries. How many optometrists have even worked with 7-0 Vicryl suture on the face? I know this is not part of your training.

I don't think optometrists should be doing lid surgery. I also don't think some ophthalmologists should be doing certain procedures. One reason is that some surgeon's have terrible hands and they really scare me. The second reason is some omd's don't have adequate training, as in my example above.Using the same example, during his residency he did'nt one lasik procedure. He took a wet lab and now he also specializes in lasik. He as done approximately 15 cases in 22 month's. He is a very good friend of mine and I wish him the best, but I feel he should have someone with him when he is doing some of these procedures. Ophthalmology should have some sort of control on who should be proforming surgery after residency. We have all seen very bright residents with terrible hands these people need more training. So if some omd's after 3 years of training can't do surgery what makes you think od's will be able to do it. And if they do get the chance to do ce(and I think we are getting ahead of ourselves) I don't think the general public will go to them for two reasons 1. there isn't enough surgery to go around . 2. The public want's an exprienced surgeon not one who did one case and got sued. We have bigger problem's in health care.

 

[Andrew_Doan]

I agree with many things you state above. There are several ways to obtain additional training: wet labs, seminars, books, working with colleagues, and fellowship training. Many new procedures can be learned easier for surgeons because we have already developed fundamental surgical skills; thus, a wet lab or seminar, for example, may be feasible for someone learning a new method for ptosis repair that is different than the method learned during residency. However, other procedures should not be performed without structured training, e.g., membrane peel.

I also agree with you that physicians need to demonstrate surgical and medical competency before they can practice.

We're currently experiencing an evolution in ophthalmology residency training and the demonstration of competency. Andrew Lee, MD and Keith Carter, MD at Iowa are leading the way in developing tools to assess resident competency in surgery and medicine. Soon, we'll see residents graduating with a portfolio detailing their surgical and medical experiences. Hospitals and state medical boards may require this before allowing certain surgical and medical privileges. My field is starting to police itself and demand higher standards from physicians.

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15465540

Ophthalmology. 2004 Oct;111(10):1807-12.

Managing the new mandate in resident education: a blueprint for translating a national mandate into local compliance.

Lee AG, Carter KD.

Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA. [email protected]

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) has mandated that all residency programs implement an assessment process of 6 core competencies. Assessment of surgical competence is also included in the mandate. We describe our local efforts to meet this new mandate. DESIGN: Systematic literature review. METHODS: A systematic MEDLINE search (1996-2003) of the literature on residency assessment tools was performed. All relevant titles were reviewed by a content expert, abstracts were selected, and all appropriate full articles were reviewed. The Department of Ophthalmology at the University of Iowa formalized the competency review process by forming an ad hoc departmental task force for "Meeting the Competencies" composed of clinicians, technical staff, education specialists, the program director, the director of residency curriculum, the medical student director, and residents. RESULTS: The task force reviewed the available literature, reviewed potential best practices, and reached consensus on an implementation plan. The following specific criteria for the assessment process were proposed: (1) there should be multiple assessments by multiple observers using multiple tools at multiple time points, (2) the tools should be reliable, reproducible, and valid; (3) the tools must be practical (i.e., feasible, convenient, low time commitment, easy to use, and inexpensive to implement and maintain); (4) the tools must produce qualitative and quantitative data, with direct linkage to improvement in educational outcomes in the future; (5) the assessment process must be linked to explicit and public learning objectives; and (6) the grading scale should be open and clearly defined, and the process should be judged as fair and accurate by both faculty and residents. The Meeting the Competencies task force reviewed all of the available tools from the literature and recommended a pilot implementation matrix matching specific tools to individual competencies. The 6 pilot tools include (1) written and oral examinations, (2) a 360 degrees global evaluation form (using multiple observers from different perspectives, including nurses, technicians, fellow residents, and patients, to provide a wider assessment), (3) a resident portfolio, (4) direct observation of operative performance and clinical examination, (5) a phone encounter tool, and (6) a journal club tool. CONCLUSION: We propose a potential blueprint for meeting the challenge of assessing the new ACGME competencies in ophthalmology and translating the national mandate into local compliance.

 

[Andrew_Doan]

Another victory for patient care and safety: http://forums.studentdoctor.net/showthread.php?t=167910

 

[USAF_Dentman]

Sorry for this question.....

If optometrists want the same scope of practicing rights as opthamologists, then why dont they just go the MD/DO route?

It just doesnt make sense to me....

 

[Andrew_Doan]

Sorry for this question.....

If optometrists want the same scope of practicing rights as opthamologists, then why dont they just go the MD/DO route?

It just doesnt make sense to me....

1) Time. I did a PhD too, and I spent the last 12 years after college in medical school, graduate school, and ophthalmology residency. Now I'll spend an additional year in ophthalmic pathology. My MD colleagues spent 8 years after college and possibly 1-2 additional years in fellowship.

2) Cost. Medical School is expensive, and medical graduates completing residency incur additional costs when the interest compounds into the loan balance.

3) Competition. Must be accepted into medical school first, but the most difficult task is matching into ophthalmology residency.

4) Life Style. Optometrist pick the field because of lifestyle. Most do not know what it's like to take call and work with inpatients. Without a general medicine background, optometrists have no idea the seriousness of caring for inpatients. For example, we performed a lid reconstruction on a patient s/p Mohs and decided to keep the patient in the hospital to recover from anesthesia. At 5:00 AM the patient had two episodes of coffee grounds hematemesis (500 cc). The patient has no history of gastric ulcer disease or GI bleeds, but he is taking plavix and ASA s/p cardiac stenting in the fall. I checked his Hb/Hct and it was 9.9/28%. I check orthostatics, and he was symptomatic and his heart rate increased upon standing. I called internal medicine, but in the mean time, I typed & crossed 2 units of PRBCs and transfused the patient. I started two large bore IVs. I passed a NG tube and found more coffee grounds but no active bleed. I tell this story to illustrate how a general medicine background assists in caring for patients. Although this patient only had an eyelid problem after Mohs, it was fortunate that the patient was admitted for recovery after surgery, and that the ophthalmology team acted promptly, stabilized the patient, and transferred the patient to internal medicine. I am certain that optometrists have no experience in managing GI bleeds and hypotensive patients (I held his morning dose of metoprolol and increased his IV while waiting for the PRBCs). While optometrists call for help (911?), the patient's Hb/Hct would have dropped resulting in a MI due to his serious cardiac history (because he had two additional episodes of hematemesis) before internal medicine could see him.

For those who argue that a general medical education is not needed to perform surgery, consider my story above because you'll never know when you have to use your general medicine knowledge to care for your patients.

5) Because of the above, it is far easier for optometrist to claim they have the knowledge and skills and sneak laws into legislation and the VA surgical handbook to allow them surgical rights. However, it is clear that the veterans and policy makers view that the recent push for optometric laser surgery in the VA was beyond their scope of practice.

 

[Richard_Hom]

..."For those who argue that a general medical education is not needed to perform surgery, consider my story above because you'll never know when you have to use your general medicine knowledge to care for your patients.

5) Because of the above, it is far easier for optometrist to claim they have the knowledge and skills and sneak laws into legislation and the VA surgical handbook to allow them surgical rights. However, it is clear that the veterans and policy makers view that the recent push for optometric laser surgery in the VA was beyond their scope of practice.

Dr. Doan,

Thanks for your post on this subject.

1. If a patient was a "suitable" canddiate for a surgical procedure with a unremarkable medical history and had an H&P just prior to surgery, what would be the chances of an unanticipated complication in external non-invasive laser eye surgery?

2. If a patient had an unremarkable and non-contributory medical history and H&P, what would be the chances of an unanticipated complication in an excision of a simple pterygium?

3. If the above two cases were done in a hospital setting (note: not in an office!) would there be sufficient back up if something happened. I'm asking because I worked for some time in various settings and when a code blue occured, the physician ophthalmologist immediately stepped back and let the code blue team work and immediately asked for 911. In the 20 cirucmstances I've seen, at no time did the outpatient-based ophthalmologist do more than call 911.

4. Your experience in residency prepares you for working on complicated cases, but if someone was "cherry-picking" easy non-complicated cases, would not such a circumstance be minimal or extremely rare?

5. Again, I am not advocating surgical privileges for optometrists. I'm just asking some explanation of the assumptions that some people have on this subject.

Regards,
Richard Hom, OD,FAAO
San Mateo, CA

 

[speyeder]

Dr. Doan,

Thanks for your post on this subject.

1. If a patient was a "suitable" canddiate for a surgical procedure with a unremarkable medical history and had an H&P just prior to surgery, what would be the chances of an unanticipated complication in external non-invasive laser eye surgery?

2. If a patient had an unremarkable and non-contributory medical history and H&P, what would be the chances of an unanticipated complication in an excision of a simple pterygium?

3. If the above two cases were done in a hospital setting (note: not in an office!) would there be sufficient back up if something happened. I'm asking because I worked for some time in various settings and when a code blue occured, the physician ophthalmologist immediately stepped back and let the code blue team work and immediately asked for 911. In the 20 cirucmstances I've seen, at no time did the outpatient-based ophthalmologist do more than call 911.

4. Your experience in residency prepares you for working on complicated cases, but if someone was "cherry-picking" easy non-complicated cases, would not such a circumstance be minimal or extremely rare?

5. Again, I am not advocating surgical privileges for optometrists. I'm just asking some explanation of the assumptions that some people have on this subject.

Regards,
Richard Hom, OD,FAAO
San Mateo, CA

I think the point is that:

1) In medicine, you never know what can happen. Just because a patient has a non-contributory medical history doesn't mean that complications can't arise. Therefore, if you are going to perform surgery, you better be prepared to deal with emergencies in case something goes wrong.

2) No matter how rare these complications are, at least ophthalmologists receive training in the management of non-ocular, medical problems. Optometrists don't.

3) The idea that optometrists can "cherry pick" non-complicated surgical cases as a way to skirt the fact they lack the medical knowledge and experience to take care of emerging medical complications is like playing russian roulette. Again, no one can predict what can happen. Sometimes things aren't as routine as they might seem.

4) Ophthalmologists are uniquely qualified to handle both the surgical and medical management of patients with ophthalmic problems.

5) Optometrists are not.

 

[Andrew_Doan]

Dr. Doan,

Thanks for your post on this subject.

1. If a patient was a "suitable" canddiate for a surgical procedure with a unremarkable medical history and had an H&P just prior to surgery, what would be the chances of an unanticipated complication in external non-invasive laser eye surgery?

2. If a patient had an unremarkable and non-contributory medical history and H&P, what would be the chances of an unanticipated complication in an excision of a simple pterygium?

3. If the above two cases were done in a hospital setting (note: not in an office!) would there be sufficient back up if something happened. I'm asking because I worked for some time in various settings and when a code blue occured, the physician ophthalmologist immediately stepped back and let the code blue team work and immediately asked for 911. In the 20 cirucmstances I've seen, at no time did the outpatient-based ophthalmologist do more than call 911.

4. Your experience in residency prepares you for working on complicated cases, but if someone was "cherry-picking" easy non-complicated cases, would not such a circumstance be minimal or extremely rare?

5. Again, I am not advocating surgical privileges for optometrists. I'm just asking some explanation of the assumptions that some people have on this subject.

Regards,
Richard Hom, OD,FAAO
San Mateo, CA

1) The point is that complications and co-morbidities are unpredictable (e.g., sometimes patients do not report everything). If one is not trained to recognized co-morbidities (i.e. optometrists), then how will the caregiver even recognize the potential problem? You're assuming that optometrists are trained to recognize medical co-morbidities. In addition, without medical training, how can optometrists be qualified to do a H&P??? This doesn't make sense to me.

2) Excision of ptyergium may require sedation or pain management as well as post-operative management of nausea. Reactions to medications are real and can be serious. Even the stress of surgery may precipitate an MI or stroke in a patient with an otherwise "negative" medical history. How many MIs have you managed? I feel comfortable recognizing the symptoms and manage the MI until I can transfer the patient. Many of your colleagues are advocating doing pterygiums in underserved areas, which implies that the surgery will be done in an ASC setting or where medical services are not readily available. A PT with a MI may be dead before EMS arrives and transfers the patient. If the optometrist is performing the surgery in a main hospital setting, then why do we need the optometric surgeon when there will surely be a local ophthalmologist available?

3) In my story with the GI bleed, this was NOT a code blue situation. Early intervention saved this patient from having a MI and admission to the MICU. However, under the care of non-medical clinicians (i.e. optometrists), the risk is higher that prompt medical attention would have been delayed; thus, you can dial 911 or code blue when the patient is crashing. I prefer to intervene and prevent the patient from coding.

There are certain things that only 911 can help; however, there are steps that can be taken to stabilize the patient before EMS arrives, e.g. in the case of an MI, ASA, morphine, O2, and treating hypotension/hypertension etc... In my situation on the inpatient service, I treated the hypotension, transfused with pRBCs, and discontinued inappropriate medications. The last I checked, no optometry school teaches these things because it's not the goal of optometry school to train medical physicians.

4) Why should optometrists have the right to "cherry pick"? Do we need more surgeons that badly? Also, medical complications will present in the most unlikely patients. This disregard for what could happen is common amongst professionals who are less trained. Cherry picking does help anyone, except for the optometrist who is trying to expand their scope of practice and be pseudo-ophthalmologists.

 

[Richard_Hom]

1) The point is that complications and co-morbidities are unpredictable (e.g., sometimes patients do not report everything). If one is not trained to recognized co-morbidities (i.e. optometrists), then how will the caregiver even recognize the potential problem? You're assuming that optometrists are trained to recognize medical co-morbidities. In addition, without medical training, how can optometrists be qualified to do a H&P??? This doesn't make sense to me.

2) Excision of ptyergium may require sedation or pain management as well as post-operative management of nausea. Reactions to medications are real and can be serious. Even the stress of surgery may precipitate an MI or stroke in a patient with an otherwise "negative" medical history. How many MIs have you managed? I feel comfortable recognizing the symptoms and manage the MI until I can transfer the patient. Many of your colleagues are advocating doing pterygiums in underserved areas, which implies that the surgery will be done in an ASC setting or where medical services are not readily available. A PT with a MI may be dead before EMS arrives and transfers the patient. If the optometrist is performing the surgery in a main hospital setting, then why do we need the optometric surgeon when there will surely be a local ophthalmologist available?

3) In my story with the GI bleed, this was NOT a code blue situation. Early intervention saved this patient from having a MI and admission to the MICU. However, under the care of non-medical clinicians (i.e. optometrists), the risk is higher that prompt medical attention would have been delayed; thus, you can dial 911 or code blue when the patient is crashing. I prefer to intervene and prevent the patient from coding.

There are certain things that only 911 can help; however, there are steps that can be taken to stabilize the patient before EMS arrives, e.g. in the case of an MI, ASA, morphine, O2, and treating hypotension/hypertension etc... In my situation on the inpatient service, I treated the hypotension, transfused with pRBCs, and discontinued inappropriate medications. The last I checked, no optometry school teaches these things because it's not the goal of optometry school to train medical physicians.

4) Why should optometrists have the right to "cherry pick"? Do we need more surgeons that badly? Also, medical complications will present in the most unlikely patients. This disregard for what could happen is common amongst professionals who are less trained. Cherry picking does help anyone, except for the optometrist who is trying to expand their scope of practice and be pseudo-ophthalmologists.

Dr. Doan,

1. Do you your own H&P? or would a general internist or family practice do it. By protocol at our hospital, the H&P is done prior to ophthalmic surgery in all cases.

2. In many underserved areas, ophthalmologists are unwilling to see patients under the schema of limited or no reimbursement. (under served could mean urban or suburban). I have no arguement referring complicated medical patients or complicated eye problems to ophthalmologists. I might have trouble trying to get an ophthalmologist to see one of my patients if it is not 'complicated'. Should this patient be rationed all eye care until an ophthalmologist is "ready to see them"?

3. In limited circumstances, I believe that certain well-defined procedures and in certain environments can can be done by optometrists safely and cost effectively.

4. This is the type of "cherry picking" I'm talking about. Cases not severe enough to get the ophthalmologists to see but sufficient serious enough that the quality of life for the patient is affected.

Thanks again for your rationale response to my query.

Richard

 

[Andrew_Doan]

Dr. Doan,

1. Do you your own H&P? or would a general internist or family practice do it. By protocol at our hospital, the H&P is done prior to ophthalmic surgery in all cases.

2. In many underserved areas, ophthalmologists are unwilling to see patients under the schema of limited or no reimbursement. (under served could mean urban or suburban). I have no arguement referring complicated medical patients or complicated eye problems to ophthalmologists. I might have trouble trying to get an ophthalmologist to see one of my patients if it is not 'complicated'. Should this patient be rationed all eye care until an ophthalmologist is "ready to see them"?

3. In limited circumstances, I believe that certain well-defined procedures and in certain environments can can be done by optometrists safely and cost effectively.

4. This is the type of "cherry picking" I'm talking about. Cases not severe enough to get the ophthalmologists to see but sufficient serious enough that the quality of life for the patient is affected.

Thanks again for your rationale response to my query.

Richard

1) Every ophthalmologist I know do their own H&P prior to the surgery. At Iowa, we do them within 30 days of the surgery. Why should we incur more costs by having FP or IM do the H&P? We are the surgeons, and we need to know the health of the patient.

2) I doubt optometrists will be willing to serve people without insurance; thus, making a new optometric surgeon helps no one.

3) I respect your opinion. But your opinion is from someone not trained in medicine and surgery; thus, I don't value your opinion.

4) There is already a pathway for "cherry picking" safely. We have general ophthalmologists who will do the straight forward surgeries. The more difficult cases will be referred to the ophthalmologists with fellowship training. Optometry has no business cherry picking surgical cases.

 

[odieoh]

Dr. Doan,


2. In many underserved areas, ophthalmologists are unwilling to see patients under the schema of limited or no reimbursement. (under served could mean urban or suburban). I have no arguement referring complicated medical patients or complicated eye problems to ophthalmologists. I might have trouble trying to get an ophthalmologist to see one of my patients if it is not 'complicated'. Should this patient be rationed all eye care until an ophthalmologist is "ready to see them"?


4. This is the type of "cherry picking" I'm talking about. Cases not severe enough to get the ophthalmologists to see but sufficient serious enough that the quality of life for the patient is affected.

Thanks again for your rationale response to my query.

Richard

Dr. Hom--

1. Are you saying that the reason Optometrists are pushing for surgical rights is because they are eager to "see patients under the schema of limited or no reimbursement?" I don't think so. If ophthalmologists are truly unwilling to see certain patients because of concerns about reimbursement, I am quite certain that an optometrist dabbling in the surgical realm would be equally unwilling for the same reasons.

2. Ophthalmologists are concerned caregivers and anytime a patient has a condition which is "serious enough that the quality of life for the patient is affected," ophthalmologists are trained to treat, either medically or surgically. You seem to be implying that there is widespread neglect by ophthalmologists, that OMD's wont see or treat patients until they become "complicated." I think most ophthalmologists would take exception to this.

3. One important point is that OMD's are trained when and when NOT to intervene surgically, and often when the decision is made NOT to intervene, the patient is not happy with that decision. One big pitfall to your cherry picking idea is that you would probably be getting a lot of these folks demanding surgery from anyone willing to perform it. And of course, Dr. Cherrypicker, OD, will be more than willing to step in and slice away. Via this route, Surgical OD's will be a wonderful conduit for turning previously uncomplicated patients into complicated ones. You are claiming that optometric surgeons will only perform surgery on those very tame, uncomplicated cases, but unless you have been through a surgical residency and seen the full spectrum of disease and the appropriate treatments thereof, how can you possibly discern which patients those are? You can't. Just my two cents.

 

[Andrew_Doan]

I agree with many things you state above. There are several ways to obtain additional training: wet labs, seminars, books, working with colleagues, and fellowship training. Many new procedures can be learned easier for surgeons because we have already developed fundamental surgical skills; thus, a wet lab or seminar, for example, may be feasible for someone learning a new method for ptosis repair that is different than the method learned during residency. However, other procedures should not be performed without structured training, e.g., membrane peel.

I also agree with you that physicians need to demonstrate surgical and medical competency before they can practice.

We're currently experiencing an evolution in ophthalmology residency training and the demonstration of competency. Andrew Lee, MD and Keith Carter, MD at Iowa are leading the way in developing tools to assess resident competency in surgery and medicine. Soon, we'll see residents graduating with a portfolio detailing their surgical and medical experiences. Hospitals and state medical boards may require this before allowing certain surgical and medical privileges. My field is starting to police itself and demand higher standards from physicians.

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15465540

Ophthalmology. 2004 Oct;111(10):1807-12.

Managing the new mandate in resident education: a blueprint for translating a national mandate into local compliance.

Lee AG, Carter KD.

Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA. [email protected]

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) has mandated that all residency programs implement an assessment process of 6 core competencies. Assessment of surgical competence is also included in the mandate. We describe our local efforts to meet this new mandate. DESIGN: Systematic literature review. METHODS: A systematic MEDLINE search (1996-2003) of the literature on residency assessment tools was performed. All relevant titles were reviewed by a content expert, abstracts were selected, and all appropriate full articles were reviewed. The Department of Ophthalmology at the University of Iowa formalized the competency review process by forming an ad hoc departmental task force for "Meeting the Competencies" composed of clinicians, technical staff, education specialists, the program director, the director of residency curriculum, the medical student director, and residents. RESULTS: The task force reviewed the available literature, reviewed potential best practices, and reached consensus on an implementation plan. The following specific criteria for the assessment process were proposed: (1) there should be multiple assessments by multiple observers using multiple tools at multiple time points, (2) the tools should be reliable, reproducible, and valid; (3) the tools must be practical (i.e., feasible, convenient, low time commitment, easy to use, and inexpensive to implement and maintain); (4) the tools must produce qualitative and quantitative data, with direct linkage to improvement in educational outcomes in the future; (5) the assessment process must be linked to explicit and public learning objectives; and (6) the grading scale should be open and clearly defined, and the process should be judged as fair and accurate by both faculty and residents. The Meeting the Competencies task force reviewed all of the available tools from the literature and recommended a pilot implementation matrix matching specific tools to individual competencies. The 6 pilot tools include (1) written and oral examinations, (2) a 360 degrees global evaluation form (using multiple observers from different perspectives, including nurses, technicians, fellow residents, and patients, to provide a wider assessment), (3) a resident portfolio, (4) direct observation of operative performance and clinical examination, (5) a phone encounter tool, and (6) a journal club tool. CONCLUSION: We propose a potential blueprint for meeting the challenge of assessing the new ACGME competencies in ophthalmology and translating the national mandate into local compliance.

Outlined and explained in detail here: http://www.eyerounds.org/competencies.htm

 

[smiegal]

In limited circumstances, I believe that certain well-defined procedures and in certain environments can can be done by optometrists safely and cost effectively.

In your opinion, Dr. Hom, which procedures fall into the aforementioned category? I'm particularly interested in those nearing the border at which you would decide it appropriate to refer to an OMD. I know you have stated that you are not promoting optometric "surgical rights," so I was interested in your take on approximately where that borderline exists.