MDs doing refractions (non-OMDs)

[alferec]

Is that true that MDs (who are not ophthalmologists) can refract and write glasses prescriptions? I spoke to a family practitioner who was in the Navy, and he said he got a crash course in refraction in the past, and he was doing refractions on patients on a ship since there were no optometrists (or OMDs) on board. I know that MDs have pretty much an unlimited scope, but I haven't heard of them doing refractions prior to meeting this guy...

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[Dr.Millisevert]

Is that true that MDs (who are not ophthalmologists) can refract and write glasses prescriptions? I spoke to a family practitioner who was in the Navy, and he said he got a crash course in refraction in the past, and he was doing refractions on patients on a ship since there were no optometrists (or OMDs) on board. I know that MDs have pretty much an unlimited scope, but I haven't heard of them doing refractions prior to meeting this guy...

I'm a dentist and some MDs take out teeth in the ER when it is needed and there isn't a dentist around.. but no MD is going to go out and set up a private practice as a dentist. The same is true for optometry. They do it if it is needed and there isn't an optometrist around. I really wouldn't worry too much.

 

[IndianaOD]

Is that true that MDs (who are not ophthalmologists) can refract and write glasses prescriptions? I spoke to a family practitioner who was in the Navy, and he said he got a crash course in refraction in the past, and he was doing refractions on patients on a ship since there were no optometrists (or OMDs) on board. I know that MDs have pretty much an unlimited scope, but I haven't heard of them doing refractions prior to meeting this guy...

Some non-OMD MDs have gotten in a bit of hot water for doing refractions and billing for them.

 

[362.04]

Dear alferec,

I've served underway with USS Abraham Lincoln and the USS Carl Vinson, In both cases, "flight surgeons" were the primary personnel doing refractions. I don't believe that optometrists are "routinely" stationed on a deployment on a nuclear carrier. Instead, the flight surgeons are tasked to do it. They even use the slit lamp. A full lane is available on these carriers.

It is a legitimate task for the flight surgeons.

 

[qwopty99]

In Ontario, refractions by non-ophthalmologic MDs are very common.

 

[aphistis]

I'm a dentist and some MDs take out teeth in the ER when it is needed and there isn't a dentist around.. but no MD is going to go out and set up a private practice as a dentist. The same is true for optometry. They do it if it is needed and there isn't an optometrist around. I really wouldn't worry too much.

Do they seriously? Does the ER schedule them with your clinic afterward to get the root tips out?

 

[Dr.Millisevert]

Do they seriously? Does the ER schedule them with your clinic afterward to get the root tips out?

Sorry, I realise I wasn't very clear. Not at my hospital (because we have a Maxfacs team and 2 dental residents). I was simply stating that in some rural clinics/hospitals with no dental/OMFS support personnel. ER staff have in the past pulled teeth that are "blowing in the wind" and/or have done an I&D on a dental abscess if it was an absolute emergency (threat of airway compromise, etc) and then referred to a dentist for followup.

 

[Dr. Dai Phan]

Do they seriously? Does the ER schedule them with your clinic afterward to get the root tips out?

I know some ENTs who take out teeth in the OR while doing maxillectory too when no dentists are available. I also gave lectures to ENT staff on how to do interim obturators in cases where they can't find a maxillofacial prosthodontist to do the work. I also told them that this is for last resort only. DP

 

[IndianaOD]

Man, the dental forums must be boring!

Dentists should just be careful the family MDs don't see the money in pulling teeth. Many are trying to find other income streams and their license lets them do anything!

We have a general practicioner around here making big bucks doing dermatology stuff.

 

[Dr. Dai Phan]

Man, the dental forums must be boring!

Dentists should just be careful the family MDs don't see the money in pulling teeth. Many are trying to find other income streams and their license lets them do anything!

We have a general practicioner around here making big bucks doing dermatology stuff.

I don't see any sensible physicians doing things that are not in their training. For sure not in dentistry because they are not trained ( or licensed) in doing such procedures. I can see GP doing dermatology since that is part of their training as long as they don't getting into the deep end. DP

 

[IndianaOD]

I don't see any sensible physicians doing things that are not in their training. For sure not in dentistry because they are not trained ( or licensed) in doing such procedures. I can see GP doing dermatology since that is part of their training as long as they don't getting into the deep end. DP

DP

It is my understanding that they have unlimited scope of practice. Is this not the case?

General MDs aren't properly trained to diagnose and treat red eyes either, but they do all the time.

 

[aphistis]

DP

It is my understanding that they have unlimited scope of practice. Is this not the case?

General MDs aren't properly trained to diagnose and treat red eyes either, but they do all the time.

Sure, MD's have an unlimited license, but that wouldn't exempt a physician from liability if s/he went to town with a handpiece and scaler inside someone's mouth.

 

[Dr. Dai Phan]

DP

It is my understanding that they have unlimited scope of practice. Is this not the case?

General MDs aren't properly trained to diagnose and treat red eyes either, but they do all the time.

MDs can treat diseases of the oral cavity like giving pain meds and antibiotics. ER docs do it all the time until the dentist can be consulted. But they can't do any irreversible procedures like extraction of teeth or doing fillings. That is practicing dentistry without the license. So No, they don't have unlimited scope of practice. On your second statement, are you implying that only ODs can diagnose and treat red eyes? DP

 

[VA Hopeful Dr]

MDs can treat dieases of the oral cavity like giving pain meds and antibiotics. ER docs do it all the time until the dentist can be consulted. But they can't do any irreversible procedures like extraction of teeth or doing fillings. That is practicing dentistry without the license. So No, they don't have unlimited scope of practice. On your second statement, are you implying that only ODs can diagnose and treat red eyes? DP

Technically, at least in my state, MD/DOs can do anything they want, medically. The tricks are a) not getting sued) and b) finding somewhere that will let you do other things.

An MD could open a dental clinic tomorrow if he had the right tools. On the other hand, he'd likely be sued w/in a week or so.

 

[Dr. Dai Phan]

Technically, at least in my state, MD/DOs can do anything they want, medically. The tricks are a) not getting sued) and b) finding somewhere that will let you do other things.

An MD could open a dental clinic tomorrow if he had the right tools. On the other hand, he'd likely be sued w/in a week or so.

Hello,

I beg to differ. I sure like to see the reaction of the State Dental Board seeing this MD applying for dental licensure. I wonder if you are taught dentistry in your medical curriculum? DP

 

[KHE]

Hello,

I beg to differ. I sure like to see the reaction of the State Dental Board seeing this MD applying for dental licensure. I wonder if you are taught dentistry in your medical curriculum? DP

This is not my area of expertise but my understanding is that a medical license would allow them to legally perform those procedurs. There is no reason to apply to the dental board for dental licensure because the medical license already grants them them the priviledges they would be seeking for.

Now, certainly it wouldn't shield them from any sort of civil action in the event that things went south but I don't think that they would need a dental license.

 

[IndianaOD]

This is not my area of expertise but my understanding is that a medical license would allow them to legally perform those procedurs. There is no reason to apply to the dental board for dental licensure because the medical license already grants them them the priviledges they would be seeking for.

Now, certainly it wouldn't shield them from any sort of civil action in the event that things went south but I don't think that they would need a dental license.

Agreed, there is no need for dental licensure. Besides the courts, there is nothing stopping them.

 

[VA Hopeful Dr]

Hello,

I beg to differ. I sure like to see the reaction of the State Dental Board seeing this MD applying for dental licensure. I wonder if you are taught dentistry in your medical curriculum? DP

OK, so I just read both the dentistry and physician sections in the state code of laws. I'm no lawyer, but here's what I found (summarized).

For physicians, the law about us makes a special exception saying we are not prohibited to practice dentistry in accordance with state law.

The dental part also has a section that makes a point of saying again that physicians are not prohibited from practicing dentistry when qualified by law to do so.

So, basically, the law doesn't take sides as I could find nothing else about this. I expect the Medical Board has, at some point, had something to say about that but I don't think their records are all online for me to search.

 

[Oculomotor]

A medical license permits an MD or DO to treat "any ailment of the human condition with medicine and surgery." Technically they can do ANYTHING they want to.....(My last visit to the statehouse I asked about this in my home state and confirmed it.) The optometry law states that if anybody BUT an MD or DO is doing optometry procedures then they are practicing optometry and are subject to the optometric board's authority...This also applies to the dental board as well regarding dental procedures. They can practice dentistry, optometry, and podiatry and just label it as practicing medicine doing the SAME procedures. The liablity aspect of it would be absurd considering we live in a litigious society. If anybody needs sources I can provide them.....


word

 

[Dr.Millisevert]

A medical license permits an MD or DO to treat "any ailment of the human condition with medicine and surgery." Technically they can do ANYTHING they want to.....(My last visit to the statehouse I asked about this in my home state and confirmed it.) The optometry law states that if anybody BUT an MD or DO is doing optometry procedures then they are practicing optometry and are subject to the optometric board's authority...This also applies to the dental board as well regarding dental procedures. They can practice dentistry, optometry, and podiatry and just label it as practicing medicine doing the SAME procedures. The liablity aspect of it would be absurd considering we live in a litigious society. If anybody needs sources I can provide them.....


word

Dentistry has a very high overhead.. hell.. dental chairs alone costs over 75k usually. There is a lot an MD would have to learn and practice before he/she would even be able to cut a crown, an MOD amalgam, or how about an upper molar endo. I doubt even if they 'could' do it.. that they would even want to test the waters unless they had actually gone to dental school. Huge financial and liability risk. I'd be interested to see how long it took an MD who limited their practice to "general dentistry" to be sued.. not be other dentists.. but by the public.

Personally.. as a dentist. I'm not too worried.

 

[VA Hopeful Dr]

Dentistry has a very high overhead.. hell.. dental chairs alone costs over 75k usually. There is a lot an MD would have to learn and practice before he/she would even be able to cut a crown, an MOD amalgam, or how about an upper molar endo. I doubt even if they 'could' do it.. that they would even want to test the waters unless they had actually gone to dental school. Huge financial and liability risk. I'd be interested to see how long it took an MD who limited their practice to "general dentistry" to be sued.. not be other dentists.. but by the public.

Personally.. as a dentist. I'm not too worried.

Of course no MD wants to do that, that's not the issue. All I'm saying is that if some MD wanted to, he/she could attempt to do what dentists do. Probably fail, get sued, lose license... but its not against the law. Not as far as I can tell, at any rate.

 

[eyestrain]

Dentistry has a very high overhead.. hell.. dental chairs alone costs over 75k usually.

For real? THe last one I was in didn't seem all that different than my optometry exam chair. What the hell make up the 70K++ difference?

 

[Dr.Millisevert]

For real? THe last one I was in didn't seem all that different than my optometry exam chair. What the hell make up the 70K++ difference?

Have a look... hmm.. probably the plumbing, electrics, pressure system for the high and slow speed drills, water filter system, motor, fibre optics.

I can think of lots of things... adds up to a lot.

 

[Dr. Dai Phan]

This is not my area of expertise but my understanding is that a medical license would allow them to legally perform those procedurs. There is no reason to apply to the dental board for dental licensure because the medical license already grants them them the priviledges they would be seeking for.

Now, certainly it wouldn't shield them from any sort of civil action in the event that things went south but I don't think that they would need a dental license.

If the physician has the priviledges to practice dentistry, he is no more prone to liability than a licensed dentist unless the act is grossly negliegence. The high risk of being sued as an MD practicing dentistry tells me that there is something wrong about dentistry priviledges included in the medical license. I will check with the ADA and AMA and see what they say. Maybe I will learn something that I never knew was possible. DP

 

[Dr. Dai Phan]

For real? THe last one I was in didn't seem all that different than my optometry exam chair. What the hell make up the 70K++ difference?

Dentistry has very high overhead and we are talking about 50% to 70%. The reason is not only the equipments but the laboratory cost and auxillary personel salary. Dentists need assistants at the chair side 100% of the time. In my specialty of prosthetics, I collect only 40% of what I charge for a prosthesis because I have to pay for the supplies that go into making the product, assistant salary, office rent and the technicians fee. That is why dental fees are very high and I can assure you the dentist doesn't take all this home au contrair to popular belief. DP

 

[IndianaOD]

Dentistry has very high overhead and we are talking about 50% to 70%. The reason is not only the equipments but the laboratory cost and auxillary personel salary. Dentists need assistants at the chair side 100% of the time. In my specialty of prosthetics, I collect only 40% of what I charge for a prosthesis because I have to pay for the supplies that go into making the product, assistant salary, office rent and the technicians fee. That is why dental fees are very high and I can assure you the dentist doesn't take all this home au contrair to popular belief. DP

The dentist in our building charges over $300 for a routine exam! 40% is WAY above the average OD net (28%). Really you guys have it made. If you do four $1000 procedures a day (I bet usually more than that) that is $1600 @ 40%!

I admit, I admire that! Sure beats 28% of 14 exams at $65 once insurance takes its toll. Yeah spectacles help some, but we would be lucky to clear 40% after lab and material fees...then you have to factor in the optician salaries and time plus the cash flow it takes to stock all those frames.

This is why I honestly recommend dentistry over optometry as a profession overall.

 

[Dr. Dai Phan]

If you do four $1000 procedures a day (I bet usually more than that) that is $1600 @ 40%!

Unfortunately, there are not many dentists that do four $1000 procedures a day except oral surgeons, endodontists and orthodontists or very successful cosmetic dentist. That's why these three specialties are darn competitive. Usually a 1000K are collected after 2-3 visits so actually it becomes a 333.00 per visit. DP

 

[eyestrain]

Have a look... hmm.. probably the plumbing, electrics, pressure system for the high and slow speed drills, water filter system, motor, fibre optics.

I can think of lots of things... adds up to a lot.

Oh, I thought you were just talking about the chair only. That makes more sense now.

 

[VA Hopeful Dr]

If the physician has the priviledges to practice dentistry, he is no more prone to liability than a licensed dentist unless the act is grossly negliegence. The high risk of being sued as an MD practicing dentistry tells me that there is something wrong about dentistry priviledges included in the medical license. I will check with the ADA and AMA and see what they say. Maybe I will learn something that I never knew was possible. DP

The AMA has no governing power for physicians, it is a lobbying group. I can ignore any and everything they say and I won't be breaking any laws.

I would suspect that the ADA is similar, but I have no proof of this.

 

[qwopty99]

This is starting to become a cross-discipline forum.

How about that? The OD-DDS compare-and-contrast forum, lol.


But reading about dents is pretty interesting. Expensive chair!

 

[aphistis]

Agreed, there is no need for dental licensure. Besides the courts, there is nothing stopping them.

You mention that like it's a trivial obstacle.

 

[200UL]

EVERY MD I've ever heard of that does refraction, books every 10 minutes, and I've even heard of every 5 minutes (a "sample" booking schedule would be 9-12 on a Saturday morning, 32 patients). Virtually none use the slit lamp (that's IF they have a slit lamp in the office), they don't do tonometry unless it's given to them (air-puff), and all basically just prescribe off the auto-refraction. In other words, they're there for their signature.

I hope no one minds me trying to stop the dentistry line of thinking… I agree with the above thought that with a refraction should come with a comprehensive eye exam. I’ll be the first to admit that learning how to refract takes about 2 nights of training with Dr. Zarwell’s program (http://www.medrounds.org/refract/menu.htm). After about 25-50 refractions in the clinic, one can be very efficient with routine refraction. You do not need and OD degree or OMD residency to do it. But ODs and OMDs can look at the eyes and pick up pathology related to the refraction and find other disease.

If one is in a pinch on a military base and new glasses are needed and no MD/OD in site, maybe OK. If nonEyeMDs did this on a large scale, however, they would be setting themselves up for failure. Could you imagine if a person thought they were getting an eye exam and they ended up losing vision from DM/glaucoma only to find out the examiner did not know how to look at the optic nerve/retina. I’d be pretty ticked off.

Getting back to the dentistry thought, I feel ER docs/ENT could provide initial treatment for lost filling or abscess. If the local dentists feel otherwise, they better be ready to come see patients at any hour of the day.

 

[KHE]

If nonEyeMDs did this on a large scale, however, they would be setting themselves up for failure. Could you imagine if a person thought they were getting an eye exam and they ended up losing vision from DM/glaucoma only to find out the examiner did not know how to look at the optic nerve/retina. I’d be pretty ticked off

I think the large scale failure would come not from the missed pathology, but from the fact that that tutorial is going to result in a fair number of inaccurate refractions.

It's not that the tutorial is "wrong" per se because it's a reasonable cookbook method of the technical aspects of refraction, but the thing about refraction is really that when you actually understand what it is you are doing when you "spin those dials" it makes you results much more accurate. Also, an adequate refraction can be done in 30 seconds on an eye. A really good one takes about 45 seconds. That difference can often times mean the difference between an enthusiastic patient referring people to your practice (and if you have an optical, purchasing their eyewear at your facility) and a less than satisfied patient telling everyone that there glasses "just aren't right." Worse, if you are constantly having to remake glasses, that's not good for business either.

Lastly, there is a very large difference between refracting and prescribing spectacles. I would say that more than half of my spectacle prescriptions are not the two endpoints of the monocular subjective refraction.

 

[200UL]

KHE - I agree with all your points. But many of these things would take care of themselves quickly or the patient may just tolerate a poor pair of glasses.

 

[qwopty99]

KHE - I agree with all your points. But many of these things would take care of themselves quickly or the patient may just tolerate a poor pair of glasses.

You're right. This DOES happen. Which suggests that when you have some folks return with a pair of glasses that don't work, it's likely there are MANY MORE individuals who were given a "poor pair of glasses" that managed to "tolerate" them.

It would make you wonder how many prescriptions were actually done right.

 

[IndianaOD]

KHE - I agree with all your points. But many of these things would take care of themselves quickly or the patient may just tolerate a poor pair of glasses.

Following the red or clicking until someone can see 20/25+ is easy. Its a step by step mechanical procedure just like cataract extraction is. I think there is a big difference between an acceptable cataract surgery and an excellent one. Providing the best binocular prescription is a whole different world.

I know I've said it before, but at a large VA site I worked at..they would not fill and OMD Rx because of massive remakes. Anything can be oversimplified to a fault.

 

[qwopty99]

But many of these things would take care of themselves quickly or the patient may just tolerate a poor pair of glasses.

Hmm.

 

[200UL]

I am not going to argue with your experiences, but let’s clarify a couple of things. As qwopty99 states, this is an attitude of some OMDs, not all. If it were, would people go to OMDs for glasses ever again? Are these the same OMDs doing LASIK surgery. “Oh Ms. Jones – 20/50 is not that bad – you should be happy.” Believe it or not, many of us like our patients to see well too and these crazy refractive surgeons like it when their patients are 20/15 and happy.

On the other hand, many MDs see lots of pathology (Monocular patients, 20/100 OD and 20/60 OS from AMD present refractive challenges in a busy clinic.) – maybe this blurs their perception – even for the well patients. Many of these MDs (ie retina) choose not to do refractions and that is probably for the best.

For a more personal experience of my own… Any 28 year old with no pathology should be able to read 20/15+. I was fairly ticked off when my last refraction, my OD stopped at 20/20 OD/OS. No binocular balance…. He does not know what I do for a living, but looked at me with surprised when I asked to keep going. What I can say is we did not rest at his original MRX in both eyes to get both eyes to 20/15!

My point is, there are OMDs and ODs that probably do not do the best they can with every refraction. But this is due to a lack of effort. Let’s not kid ourselves - providing the best binocular refraction is not really that hard.

 

[qwopty99]

So why did you go to an optometrist for your refraction?

 

[aphistis]

Getting back to the dentistry thought, I feel ER docs/ENT could provide initial treatment for lost filling or abscess. If the local dentists feel otherwise, they better be ready to come see patients at any hour of the day.

Oh, certainly. Palliative care is easy; a week's worth of motrin/vicodin for pain +/- PCN/clinda/flagyl for frank infection will work fine, and obviously any ER or ENT physician will be well-practiced with those meds. It's only the definitive management for these problems (placing a new restorations, performing a root canals, or doing the extractions) that lie outside the physician's training and armamentarium.

 

[200UL]

I repeat any OMD or OD can do a good a good job prescribing glasses if they want to. I am not going to sit here and pretend it is "magic". If and OMD does not want to do a good job at it, he/she should not do it. But not every OMD is bad at this.

Regarding RK, many people had great outcomes and were initially very happy. Unfortunately, everyone found out it was the gift that kept on giving and in general not as stable as a refractive procedure should be. It was the best procedure available at the time, however. I have seen some stable patients that are still happy, but I agree in general this procedure was too unpredictable over the long term. Every field in medicine is filled with procedures that become obsolete due to advances. Ophthalmology is filled with hundreds - major ones in the last 2-3 years (Laser to the fovea for CNVMs, Full thickness transplant for PBK/Fuchs).

I have had my eyes examined and refractions by both ODs and OMDs over the years. Both did a fine job in my opinion and were very capable of prescribing glasses.

 

[qwopty99]

Hey listen, everything you're saying is right. Fine.

 

[blysssful]

Hey listen. The day you find me an ophthalmologist who has had RK done on his/her own eyes, is the day I'll agree with the positive "spin" you've put on this procedure.

And as for where I work, yeah - I see RKs - the ones referred for corneal transplants.

A friend of mine is finishing his ophthalmology residency now, and I asked him if he was considering getting lasik (although I'm assuming this is different from RK), but essentially he was told that he's not allowed to get any laser correction because of the potential halo effects.

 

[qwopty99]

Quite different.

LASIK:
http://www.eyeclinicpc.com/lasik/lasik%20steps1.jpg

RK:
http://www8.utsouthwestern.edu/vgn/images/portal/cit_1801/37/36/70898wm-sl5.jpg

 

[qwopty99]

No way no how OMDs are better at "glasses" than ODs. No way no how.

 

[KHE]

I've thought about it a bit more.

In the same way ProZack claims ODs won't be more trained in eye pathology than OMDs ("No way, no how"), there's no way no how OMDs are on average, on par with optometrists at prescribing.

Optometrists are trained at dispensing glasses (edging, fitting, repair etc. of spectacles). Not in my slightest dream would I consider myself superior at this to an optician. That's what opticians DO. That is what they are responsible for, every day. Patients walk into their stores everyday asking them to repair their glasses. Yes I'm trained at spectacle dispensing, but no way would I would imagine myself equal to a licensed optician. No way no how.


For an ophthalmologist to suggest that OMDs in general are "as good" at refraction at ODs, I'm sorry but that's just incredibly fanciful. It's not that they couldn't be, but that is not their primary responsibility day-to-day. For the the optometrist, in general, it is.


So sorry 200UL, we'll have to disagree on this. You seem to think ophthalmology and optometry overlap, with ophthalmology overlapping EVERYTHING that optometry knows how to do. Sorry - the definition of optometry is not a half-trained ophthalmologist. If that were the case, how much experience does an ophthalmologist have with edging and blocking lenses? Have you ever seen an OMD take a seg height? How about you? When you take seg heights for bifocals, where do you mark? How about for PALs? Have you even done this before?


I would never have the audacity to tell an optician I'm as good at dispensing as they are.



No way no how OMDs are better at "glasses" than ODs. No way no how.

My God....the tedium of THIS thread is now giving me exotropia.

Let's just summarize, ok??

There are some things that ophthalmologists are generally "better" at than optometrists due to the nature of their training and the focus of their practices.

There are some things that optometrists are generally "better" at than ophthalmologists due to the the nautre of their training the focus of their practices.

There are some things that ophthalmologists and optometrists do about equally well due to the ubiquitousness of these things and the fact that they are common in the training and the practices of both groups of professionals.

There are some things that dentists do better than optometrists AND ophthalmologists.

There are some things that optometrists and ophthalmologists do better at than dentists.

Can we please just leave it at that, for the love of God?

 

[qwopty99]

Hey KHE

This thread is new in one respect though.


Whereas previous threads discussed ad nauseum the relative training in disease of ODs and OMDs, this is the first where an OMD positioned that they are as capable at refraction as ODs.


This is not something that we've seen before.

 

[362.04]

Hey KHE

This thread is new in one respect though.


Whereas previous threads discussed ad nauseum the relative training in disease of ODs and OMDs, this is the first where an OMD positioned that they are as capable at refraction as ODs.


This is not something that we've seen before.

Unfortunately, it is still about "us against them.."

 

[eyestrain]

Can we please just leave it at that, for the love of God?

Agreed. Pretty much every thread here lately has been absolutely mind-numbing. At least it's been generally well behaved bickering, I guess.