Well, it's nice to see that this arguement can be found in this forum, the OMD forum, seniordoc forum, and in most state legislatures around the country. I would like to address this issue from a slightly different perspective. Please note that I do not speak for optometry. I am a simply a practicing OD that has performed ALT's, YAG's and LPI's. I have never performed cataract surgery or any other procedure requiring a scapel. What I would like to propose, is that maybe organized ophthalmology has misunderstood the desires of the majority of OD's in this country. I know there is a vocal minority that has been quoted by the AMA and the AOA as saying they want to do cataract surgery. I believe this should be seen as a political tactic. Ask for more than you want with the hopes of backing down to the actual amount you want. I personally do not agree with this tactic, but unfortunately it has proven to be the most successful. Plus, historically, ophthalmology has lied or used scare tactics to state legislators in order to either halt expansion or actually push back current scope of practice. For example, when OD's were trying to get topical diagnostic agents such as phenylephrine in Califorina, OMD's took out a bottle of 10% PE and told legislators, that one drop from that bottle could kill them and if an OD has the ability to use it, patients will die. Pretty scary, huh. Well, OD's won that battle, and unless someone can prove otherwise, there have been no reported deaths attributed to an OD's use of PE. So both sides feel they need to do whatever it takes to get what they want.
What I believe the majority of the most progressive OD's want is the use of orals, injectables, and anterior seg lasers. Most OD's that are in practice, as opposed to those who spend their time lobbying, are very content with our current scope. For me, orals (which I have priviledges for in Washington state), and lasers would be helpful in my practice and would benefit patients. I have never had a patient that I felt would benefit from me using injectables. So I am going to address this issue from the position that all OD's want is the use of the Nd:Yag and Argon lasers. The rest of you can argue whether or not OD's should be able to perform catarat surgery as I do not believe I will ever see that day.
The way I see it this issue has boiled down to 3 main questions:
1) Do OD's get the proper training to perform these procedures?
2) Do we really need more providers performing these procedures?
3) How would this benefit patients and the health care system?
I'll give you my opinion:
1) The answer that this question is only a few do. NSUCO, in OK is the only optometry school that I know of that trains its students on lasers. The students perform these procedures on live patients that are referred in from either the school clinic or one of its outreach clinics. Is the training adequate? Well, according to one source on the OK board, there are approximately 290 OD's in OK performing laser procedures. It is estimated that several thousand procedures are perfomed annually. OD's have had this priviledge since the late 80's when the Yag was first introduced and the OK law had no wording preventing OD's from using them. There was a 1-2 year break in the late 90's when OMD's successfully stopped OD's until the new law was written to include lasers in '98. In all that time, there has been no reported complications due to an OD performing these procedures. So it seems to me, that by adding this curriculum to all the schools, OD's can be properly trained to perform laser procedures.
2) It's funny to me that access to care is even an issue here. The question shouldn't be how far would a patient have to travel to see an MD, because that would only justify expanded scope for rural doctors. Also, I don't see the OMD's saying "we don't need anymore eye surgeons in Seattle, so we will not allow anymore OMD's to locate there until one retires, or the population increases". Whether or not either side would like to admit it, changing the scope of practice has financial implications, more so for the OMD than for the OD. The procedures themselves are not profitable. In fact, my local corneal specialist (good friend of mine) has told me that when you include the lease and maintenence on the YAG, it is not profitable for him. So, OD's don't want this for the money. Where the OMD can make extra money is on the exam and consult fee. Considering that OD's see the majority of the patients in this country, that represents a lot of referrals for anterior seg lasers. As I said above, OD's have shown they can and will perform these procedures without complications, thereby cutting off a decent amount of referrals to OMD's.
3) I have heard the arguement that allowing OD's to perform lasers hurts patients (surgery by surgeons). Once again, there has not been one reported complication in OK. Let me explain how it can help patients and our health care system. In my practice, when I see a 70 year old Medicare patient that is pseudophakic in both eyes and has a complaint of decreased vision, I charge my normal exam fee. If I diagnose a posterior cap opacity, and refer to the local OMD that patient will be charged another exam fee plus an additional fee because it is a consult. Once the OMD confirms my diagnosis (not once have I seen an OMD disagree with my assessment on the need for a YAG) then he performs the YAG and sends the patient back to me at one week. This essentially more than doubles the cost of this encounter by having both of us see this patient. If I had been able to perform the YAG right then, there would less of a burden on Medicare. Not to mention the additional burden of lost work hours, if this patient needed a ride to both appointments and that person had to take off work to do it.
Just my opinion, and at least a more realistic look at what OD's really want and why they want it from someone in private practice.
