- Joined
- Jul 30, 2004
- Messages
- 102
- Reaction score
- 0
http://www.crstoday.com/Pages/CurrentIssue.html
I will also post the articles in the following replies
I will also post the articles in the following replies
You are using an out of date browser. It may not display this or other websites correctly.
You should upgrade or use an alternative browser.
You should upgrade or use an alternative browser.
Optometric Surgeon?
- Thread starter John_Doe
- Start date
- Joined
- Jul 30, 2004
- Messages
- 102
- Reaction score
- 0
The Scope-of-Practice Quagmire
By John F. Doane, MD, FACS, Chief Medical Editor
A Like many other medical specialties across the US right now, ophthalmology and optometry are at odds over scope-of-practice issues. Two recent and opposing actions have recently stoked this long-standing struggle between the two professions: (1) organized state optometric societies have pushed for legislation to increase optometrists? scope of practice into areas traditionally considered to be the realm of medicine; and (2) the AAO and the ASCRS recently decided to disallow doctors of optometry to attend their annual meetings unless these practitioners are employed by ophthalmologists or the ophthalmic industry.
In this issue of Cataract & Refractive Surgery Today, we wanted to present opinions from both sides on the sensitive issue of scope of practice. We explored the status quo and postulated how and by whom patients? medical and surgical care will be provided in the near future within individual states. Should ophthalmic surgery only be performed by ophthalmic surgeons, or is it appropriate for an optometrist to perform surgery with a laser or scalpel? Is ophthalmologists? traditional course of medical school and structured ophthalmic residency training overkill? Do patients understand the difference between an optometrist and an ophthalmologist? Do they recognize the differences in didactic training, resident experience, and supervised medical and surgical care training in an accredited training program? Are some groups taking advantage of their professional titles and of public ignorance to further personal agendas? The answer appears to depend upon whom you ask.
In the debate about who is best suited to perform ophthalmic surgery or operations in other surgical disciplines, the argument may be more about what the minimal educational requirements are for operating on a human patient. Frighteningly, there is a danger that the merits of education and supervised training may be trumped by which interest group?s argument, debating skill, and political/financial contributions are most convincing to individual state legislative bodies. If optometry groups? stated goal is to create a parallel or parity profession, is it appropriate that the ?equal? professions be licensed and credentialed through separate boards within a given state? In most states at present, medical doctors, doctors of osteopathy, doctors of podiatric medicine, and doctors of chiropractic fall under the auspices of the specific state board of healing arts. Optometry falls universally under its own board and acts totally and unequivocally independently of state boards of healing arts. Why? What does this arrangement allow or disallow? Should it concern the public and practitioners? These and other considerations are raised in this provocative issue of CRSToday. As always, we welcome your comments at [email protected].
By John F. Doane, MD, FACS, Chief Medical Editor
A Like many other medical specialties across the US right now, ophthalmology and optometry are at odds over scope-of-practice issues. Two recent and opposing actions have recently stoked this long-standing struggle between the two professions: (1) organized state optometric societies have pushed for legislation to increase optometrists? scope of practice into areas traditionally considered to be the realm of medicine; and (2) the AAO and the ASCRS recently decided to disallow doctors of optometry to attend their annual meetings unless these practitioners are employed by ophthalmologists or the ophthalmic industry.
In this issue of Cataract & Refractive Surgery Today, we wanted to present opinions from both sides on the sensitive issue of scope of practice. We explored the status quo and postulated how and by whom patients? medical and surgical care will be provided in the near future within individual states. Should ophthalmic surgery only be performed by ophthalmic surgeons, or is it appropriate for an optometrist to perform surgery with a laser or scalpel? Is ophthalmologists? traditional course of medical school and structured ophthalmic residency training overkill? Do patients understand the difference between an optometrist and an ophthalmologist? Do they recognize the differences in didactic training, resident experience, and supervised medical and surgical care training in an accredited training program? Are some groups taking advantage of their professional titles and of public ignorance to further personal agendas? The answer appears to depend upon whom you ask.
In the debate about who is best suited to perform ophthalmic surgery or operations in other surgical disciplines, the argument may be more about what the minimal educational requirements are for operating on a human patient. Frighteningly, there is a danger that the merits of education and supervised training may be trumped by which interest group?s argument, debating skill, and political/financial contributions are most convincing to individual state legislative bodies. If optometry groups? stated goal is to create a parallel or parity profession, is it appropriate that the ?equal? professions be licensed and credentialed through separate boards within a given state? In most states at present, medical doctors, doctors of osteopathy, doctors of podiatric medicine, and doctors of chiropractic fall under the auspices of the specific state board of healing arts. Optometry falls universally under its own board and acts totally and unequivocally independently of state boards of healing arts. Why? What does this arrangement allow or disallow? Should it concern the public and practitioners? These and other considerations are raised in this provocative issue of CRSToday. As always, we welcome your comments at [email protected].
- Joined
- Jul 30, 2004
- Messages
- 102
- Reaction score
- 0
ODs? Quest to Perform Surgery
Optometrists are striving to expand their scope of practice
to benefit patients in rural areas of the US.
By Leland Carr, OD
LIn terms of optometrists? ?quest? to perform invasive eye surgery, I believe there are some practitioners who would like to be able to do everything under the sun, probably including brain surgery. The real aims are to make eye care as convenient as possible for patients and for optometrists to provide legitimate, safe eye health care with minimal inconvenience, expense, and travel time for patients.
A classic example is the shift in optometric practice in Oklahoma?an almost 20-year-old issue?such that optometrists may perform extremely safe ophthalmic laser procedures, such as YAG capsulotomy and argon laser trabeculoplasty. The motivating factors behind this shift in surgical privileges included (1) the rural distribution of patients in need of eye health care, (2) the urban location of the ophthalmologists, (3) the multiple-day delays between identifying a patient?s need for a procedure and performing that procedure, and (4) the inability or overwhelming reluctance of a number of those patients to make the trek to Tulsa, Oklahoma City, or other faraway metropolitan cities that are heavily populated with ophthalmologists. The question that optometrists want to answer is how do we provide surgical care to patients elsewhere than Oklahoma who need it, want it, but either cannot or will not travel long distances for it?
INVASIVE SURGERY
Typically, optometrists only seek to do what I would describe as minor surgical procedures including the anterior segment laser procedures noted earlier, lid lesion removals and biopsies, punctal cautery, etc., not major, high-risk, extensively invasive procedures including retinal buckles, submacular net removals, optic nerve decompressions, etc. Any procedure that involves cutting the eye is invasive but not necessarily high-risk. Physicians in any subspecialty, not just optometry or ophthalmology, could argue that lancing a boil or popping a blister constitutes surgery by definition. At issue for optometrists are procedures such as chalazion removal, cutaneous horn removal, and wart removal around the eye, for all of which there is a huge margin of safety.
EDUCATION AND TRAINING
The public health need will dictate where additional health providers are necessary. Subsequently, it will become the responsibility of the respective schools and colleges to ensure that academia delivers the training that meets or exceeds anything necessary to achieve the competence and practitioner confidence to do the procedure.
In the late 1980s, optometry tried to model its training around ophthalmology. The assignment was to develop a training program for aspiring optometrists that met or exceeded the equivalent training that an ophthalmologist received relative to a specific procedure. As in medicine, building on a solid fundamental core education, the optometrist would receive additional highly specific training in the mastery of a technique.
For example, in the 1980s, an ophthalmologist who had completed medical school, residency training, and fellowship years before the YAG laser was developed could receive a ?post-on-your-wall? credential signifying CME course completion following a 90-minute workshop at a major conference such as the AAO?s annual meeting. Optometry has never credentialed an optometrist to use the YAG laser based upon 90 minutes of training because of state boards? insistence that optometric training exceed minimal standards acceptable elsewhere.
Ophthalmologists often use the aforementioned credentialing for privileging purposes. The credential states that an ophthalmologist has received appropriate training in a specific procedure and therefore should be considered competent to perform that procedure. Technically, however, it is not necessary for an MD or a DO to have that advanced training because of the unrestricted nature of the medical license. Optometry is a legislated profession with a scope of practice tightly defined in state laws and optometry board rules. Medicine is not similarly hampered by specific ?cans? and ?cannots? in its practice acts. Although common sense and fear of malpractice litigation dictate that both MDs and DOs stick within the comfort zone of their practice, training, and experience, technically, they do not have to.
THE REAL REASON
Money Matters and Patient Demand
To totally deny an economic motivator behind optometrists? pursuit to perform surgery would be a mistake. As in all professions, economics play a part in which procedures optometrists want to offer as part of their practice. However, the principal motivation behind the majority of optometrists? desire to perform minor surgical procedures has been patient demand. Patients trust their doctor?s of optometry to do necessary surgical or nonsurgical procedures correctly.
I am completely unaware of any optometrist?s ever having misrepresenting herself or himself as a doctor of medicine or doctor of osteopathy. The optometrist tells the patient that she/he is an optometrist and has received training in the procedure that the patient is requesting. Routinely, optometrists acknowledge not having gone to medical school.
The informed consent process makes it clear that the performer of the procedure is a licensed optometrist, nothing more and nothing less.
Refractive Surgery Comanagement
Optometrists perform the majority of eye care in this country. They detect refractive errors in patients that are amenable to laser treatment on a much more frequent basis than do ophthalmologists. If ophthalmologists want to perform more refractive procedures and they persuade optometrists to refer patients, then the ophthalmologists are successful. Refractive surgery comanagement was a concept hatched by ophthalmologists who wanted to increase optometric referrals.
MEDICAL SCHOOL/EDUCATION
I agree that patients? welfare is most protected when those performing surgery are able to recognize and manage complications and understand complex disease conditions. In all of the courses that I have either participated in or consulted on, the indications and contraindications for a procedure, the identification of complications, and their management were part of optometric training, education, and supplemental instruction.
The contemporary core curriculum in optometry prepares graduates to recognize and deal with the complications associated with the procedures that optometrists have pursued. Additionally, there are a reiteration and a review of specifics in course work that go along with our workshops.
(cont)
Optometrists are striving to expand their scope of practice
to benefit patients in rural areas of the US.
By Leland Carr, OD
LIn terms of optometrists? ?quest? to perform invasive eye surgery, I believe there are some practitioners who would like to be able to do everything under the sun, probably including brain surgery. The real aims are to make eye care as convenient as possible for patients and for optometrists to provide legitimate, safe eye health care with minimal inconvenience, expense, and travel time for patients.
A classic example is the shift in optometric practice in Oklahoma?an almost 20-year-old issue?such that optometrists may perform extremely safe ophthalmic laser procedures, such as YAG capsulotomy and argon laser trabeculoplasty. The motivating factors behind this shift in surgical privileges included (1) the rural distribution of patients in need of eye health care, (2) the urban location of the ophthalmologists, (3) the multiple-day delays between identifying a patient?s need for a procedure and performing that procedure, and (4) the inability or overwhelming reluctance of a number of those patients to make the trek to Tulsa, Oklahoma City, or other faraway metropolitan cities that are heavily populated with ophthalmologists. The question that optometrists want to answer is how do we provide surgical care to patients elsewhere than Oklahoma who need it, want it, but either cannot or will not travel long distances for it?
INVASIVE SURGERY
Typically, optometrists only seek to do what I would describe as minor surgical procedures including the anterior segment laser procedures noted earlier, lid lesion removals and biopsies, punctal cautery, etc., not major, high-risk, extensively invasive procedures including retinal buckles, submacular net removals, optic nerve decompressions, etc. Any procedure that involves cutting the eye is invasive but not necessarily high-risk. Physicians in any subspecialty, not just optometry or ophthalmology, could argue that lancing a boil or popping a blister constitutes surgery by definition. At issue for optometrists are procedures such as chalazion removal, cutaneous horn removal, and wart removal around the eye, for all of which there is a huge margin of safety.
EDUCATION AND TRAINING
The public health need will dictate where additional health providers are necessary. Subsequently, it will become the responsibility of the respective schools and colleges to ensure that academia delivers the training that meets or exceeds anything necessary to achieve the competence and practitioner confidence to do the procedure.
In the late 1980s, optometry tried to model its training around ophthalmology. The assignment was to develop a training program for aspiring optometrists that met or exceeded the equivalent training that an ophthalmologist received relative to a specific procedure. As in medicine, building on a solid fundamental core education, the optometrist would receive additional highly specific training in the mastery of a technique.
For example, in the 1980s, an ophthalmologist who had completed medical school, residency training, and fellowship years before the YAG laser was developed could receive a ?post-on-your-wall? credential signifying CME course completion following a 90-minute workshop at a major conference such as the AAO?s annual meeting. Optometry has never credentialed an optometrist to use the YAG laser based upon 90 minutes of training because of state boards? insistence that optometric training exceed minimal standards acceptable elsewhere.
Ophthalmologists often use the aforementioned credentialing for privileging purposes. The credential states that an ophthalmologist has received appropriate training in a specific procedure and therefore should be considered competent to perform that procedure. Technically, however, it is not necessary for an MD or a DO to have that advanced training because of the unrestricted nature of the medical license. Optometry is a legislated profession with a scope of practice tightly defined in state laws and optometry board rules. Medicine is not similarly hampered by specific ?cans? and ?cannots? in its practice acts. Although common sense and fear of malpractice litigation dictate that both MDs and DOs stick within the comfort zone of their practice, training, and experience, technically, they do not have to.
THE REAL REASON
Money Matters and Patient Demand
To totally deny an economic motivator behind optometrists? pursuit to perform surgery would be a mistake. As in all professions, economics play a part in which procedures optometrists want to offer as part of their practice. However, the principal motivation behind the majority of optometrists? desire to perform minor surgical procedures has been patient demand. Patients trust their doctor?s of optometry to do necessary surgical or nonsurgical procedures correctly.
I am completely unaware of any optometrist?s ever having misrepresenting herself or himself as a doctor of medicine or doctor of osteopathy. The optometrist tells the patient that she/he is an optometrist and has received training in the procedure that the patient is requesting. Routinely, optometrists acknowledge not having gone to medical school.
The informed consent process makes it clear that the performer of the procedure is a licensed optometrist, nothing more and nothing less.
Refractive Surgery Comanagement
Optometrists perform the majority of eye care in this country. They detect refractive errors in patients that are amenable to laser treatment on a much more frequent basis than do ophthalmologists. If ophthalmologists want to perform more refractive procedures and they persuade optometrists to refer patients, then the ophthalmologists are successful. Refractive surgery comanagement was a concept hatched by ophthalmologists who wanted to increase optometric referrals.
MEDICAL SCHOOL/EDUCATION
I agree that patients? welfare is most protected when those performing surgery are able to recognize and manage complications and understand complex disease conditions. In all of the courses that I have either participated in or consulted on, the indications and contraindications for a procedure, the identification of complications, and their management were part of optometric training, education, and supplemental instruction.
The contemporary core curriculum in optometry prepares graduates to recognize and deal with the complications associated with the procedures that optometrists have pursued. Additionally, there are a reiteration and a review of specifics in course work that go along with our workshops.
(cont)
- Joined
- Jul 30, 2004
- Messages
- 102
- Reaction score
- 0
EXPANSIONS OF ODs? SCOPE OF PRACTICE
Optometrists? Therapeutic Pharmaceutical Agent rights provide optometrists critical access to the tools necessary to manage complications, at least the majority of them, in the event that there is postoperative pain or infection. It is appropriate for optometrists to have formulary drug access and prescribing rights, which enable them to deal with complications quickly and efficiently.
In the states where optometrists perform minor surgical procedures or administer periocular injections, these practitioners also have the legal authority to prescribe the types of medications that are necessary to manage an adverse outcome.
ODs TO PERFORM LASER SURGERY IN the department of veterans affairs
It sets an unfortunate and unnecessary precedent to force an optometrist who has been licensed and credentialed to perform laser procedures to act under the supervision of an ophthalmologist, simply because the ophthalmologist has a different set of letters following his name. If the state optometry board has approved the adequacy and the competence of the optometrist to perform the procedure, that is sufficient, in my opinion. The training an optometrist receives is more than adequate and safeguards the well-being of the patient.
In my opinion, ophthalmologists would have liked much more dramatic restrictions of optometrists? ability to perform any type of surgical procedure in the Department of Veteran Affairs setting. Ophthalmology?s political goal was for anything remotely surgical to be declared out of the realm of optometric practice within the Department of Veteran Affairs system. At the same time, optometry would have preferred that there be no oversight or restrictive mandates on an appropriately credentialed optometrist to do the procedure. Neither ophthalmology nor optometry came out ahead.
MALPRACTICE
With some optometrists being permitted to perform minor surgical procedures including laser surgery, potential increases in malpractice insurance rates have become a common topic of optometrists? legislative discussions. To my knowledge, these rates have not risen because there have not been substantial or significant numbers of adverse outcomes.
Is what happened to ophthalmologists? malpractice premiums likely to happen to optometrists? Perhaps, but the majority of lawsuits brought against ophthalmologists involve far riskier surgeries than what optometrists are seeking to perform. Few lawsuits are brought against an ophthalmologist for an unsuccessful chalazion removal, and I am unaware of any litigation brought against an optometrist for chalazion surgery gone sour.
LOCATION
In general, newly graduated health care providers, including vision care providers, tend to congregate in urban settings. They like the lifestyle that bigger cities afford. Here in Portland, Oregon, the number of ophthalmologists and optometrists greatly exceeds residents? needs in terms of vision care. By contrast, a lot of rural Americans are dramatically underserved. I think that this distribution problem needs to be addressed by both ophthalmology and optometry. Additionally, there is a documental disparity in the type of care that underrepresented minorities receive. Optometrists and ophthalmologists ought to be working together to try to bring optimal vision care to the people who currently lack it, not fighting over the right to perform minor surgery.
Leland Carr, OD, is Dean of Pacific University, College of Optometry in Portland, Oregon, and is the immediate past president of the Association of Schools and Colleges of Optometry. He may be reached at (503) 352-2202; [email protected].
For a downloadable pdf of this article, including Tables and Figures, click here.
Optometrists? Therapeutic Pharmaceutical Agent rights provide optometrists critical access to the tools necessary to manage complications, at least the majority of them, in the event that there is postoperative pain or infection. It is appropriate for optometrists to have formulary drug access and prescribing rights, which enable them to deal with complications quickly and efficiently.
In the states where optometrists perform minor surgical procedures or administer periocular injections, these practitioners also have the legal authority to prescribe the types of medications that are necessary to manage an adverse outcome.
ODs TO PERFORM LASER SURGERY IN the department of veterans affairs
It sets an unfortunate and unnecessary precedent to force an optometrist who has been licensed and credentialed to perform laser procedures to act under the supervision of an ophthalmologist, simply because the ophthalmologist has a different set of letters following his name. If the state optometry board has approved the adequacy and the competence of the optometrist to perform the procedure, that is sufficient, in my opinion. The training an optometrist receives is more than adequate and safeguards the well-being of the patient.
In my opinion, ophthalmologists would have liked much more dramatic restrictions of optometrists? ability to perform any type of surgical procedure in the Department of Veteran Affairs setting. Ophthalmology?s political goal was for anything remotely surgical to be declared out of the realm of optometric practice within the Department of Veteran Affairs system. At the same time, optometry would have preferred that there be no oversight or restrictive mandates on an appropriately credentialed optometrist to do the procedure. Neither ophthalmology nor optometry came out ahead.
MALPRACTICE
With some optometrists being permitted to perform minor surgical procedures including laser surgery, potential increases in malpractice insurance rates have become a common topic of optometrists? legislative discussions. To my knowledge, these rates have not risen because there have not been substantial or significant numbers of adverse outcomes.
Is what happened to ophthalmologists? malpractice premiums likely to happen to optometrists? Perhaps, but the majority of lawsuits brought against ophthalmologists involve far riskier surgeries than what optometrists are seeking to perform. Few lawsuits are brought against an ophthalmologist for an unsuccessful chalazion removal, and I am unaware of any litigation brought against an optometrist for chalazion surgery gone sour.
LOCATION
In general, newly graduated health care providers, including vision care providers, tend to congregate in urban settings. They like the lifestyle that bigger cities afford. Here in Portland, Oregon, the number of ophthalmologists and optometrists greatly exceeds residents? needs in terms of vision care. By contrast, a lot of rural Americans are dramatically underserved. I think that this distribution problem needs to be addressed by both ophthalmology and optometry. Additionally, there is a documental disparity in the type of care that underrepresented minorities receive. Optometrists and ophthalmologists ought to be working together to try to bring optimal vision care to the people who currently lack it, not fighting over the right to perform minor surgery.
Leland Carr, OD, is Dean of Pacific University, College of Optometry in Portland, Oregon, and is the immediate past president of the Association of Schools and Colleges of Optometry. He may be reached at (503) 352-2202; [email protected].
For a downloadable pdf of this article, including Tables and Figures, click here.
- Joined
- Jul 30, 2004
- Messages
- 102
- Reaction score
- 0
ODs? Legislative Expansion
Optometry is trying to become ophthalmology, but by
taking major shortcuts in schooling.
H. Dunbar Hoskins, Jr, MD
Optometrists who now have the licensed right to perform laser eye surgery in Oklahoma may be able to perform the same procedure in any Department of Veteran Affairs (VA) hospital across the nation. A major problem associated with this ruling is that Oklahoma?s optometrists? surgical privileges have set a national standard. Even though Oklahoma is the only state that authorizes optometric laser surgery, the VA may allow those optometrists credentialed in Oklahoma to perform surgery throughout the country, regardless of their lack of medical schooling and preparation. Our veterans fought under the flag of the US, not the flag of Oklahoma. Why should they all be subject to the legislative vagaries of that state?
POLITICAL CLOUT
The optometry lobby at the state level continues to have a greater political influence than ophthalmology, and the former has used its power in rural states (where optometrists outnumber ophthalmologists 3:1) to achieve surgical privileges, as in Oklahoma. Optometrists will continue to use their political prowess to their regulatory advantage. It is expected that they will approach legislators in other states with the scenario, ?if we may perform surgery in the veterans? hospital in the VA system, we should be permitted to perform surgery in any state.?
Optometrists have had first-rate relationships with legislators for more than 50 years, and they have made significant contributions to legislators, thus making it difficult for legislators to refuse their requests. Legislators are passing optometric scope-of-practice expansion rulings with little understanding about what they are doing. Congresspersons do not have the time to gain a thorough understanding of each bill that crosses their desks, a situation leading them to trust the information provided by their political allies.
Doctors of medicine are governed by a natural law. It does not matter how much you plead, how big your donations are, or how much you argue on behalf of the patient; if you do not manage a disease correctly, or if the disease is overwhelming, the patient dies. You cannot dispute natural law.
Legislators and attorneys are governed by compromise and the ability to cajole, and they are influenced by dollars. Natural law does not play a role in their decision-making. Wannabe surgeons should obtain the privilege to perform surgery through education, training, and supervision, not argument, coaxing, and financial influence.
EDUCATION
Complex surgical procedures, such as laser eye surgery, require a concentration of experience and high-quality supervision during surgical preparation, performance, and postoperative follow-up. Only by completing medical school, fellowship, and residency (coupled with observing and performing numerous laser eye surgeries) will one achieve the skills of a surgeon. Optometrists should not perform surgery unless they finish medical school and all related academic training (eg, internship, fellowship, residency, etc.).
Unlike optometrists, ophthalmologists have 8 years of medical education, including surgical skills training and education on incisions and subsequent tissue reactions. That learning is the foundation for understanding medicine. A 90-minute workshop on a specific surgical procedure without this medical education does not constitute adequate training to perform a surgical procedure in humans. Two days are not enough, and neither are 4 months. Being a surgeon requires knowledge and experience that are only achieved through 8 years of medical training. To shortcut that process puts patients at risk. Patients need to ask themselves, ?Do I want someone performing the surgery who has the foundation of medical school, or do I want a 90-minute wonder?? Most patients do not know to ask this question, however, they assume someone in a white coat who calls himself ?doctor? has medical school training. That is not always true.
Although optometrists have tremendously expanded their scope of practice via legislative fiat over the last 10 years, no change has been made to the length of schooling necessary to become an optometrist. In 1992 and 1998, some leaders in optometric education stated, ?We are already stretched to our limits in providing education to our students,?1 and ?Expanding the scope of practice means expanding the curriculum, which is already bulging at the seams.?2 Optometry is expanding its scope of practice into the management of disease and the surgical realm without expanding its time for education and training. Intuitively, this situation just does not make sense.
VA SYSTEM
What has not been clearly defined is what the VA system means by ?supervision.? Ophthalmic organizations, such as the AAO, are waiting to see that term better delineated. It makes no sense for an ophthalmologist to observe an unqualified individual, such as an Oklahoma-licensed optometrist, perform a laser procedure for the first time in a state that itself does not permit such privileging. Would it not be fairer to the patient for the ophthalmologist, who has the time to supervise the procedure, to perform it himself?
There is no backlog of laser procedures in the VA system. The enormous backlog that exists is of refractions, optometry?s niche. Why do they want to move into areas for which they lack the medical training and experience instead of addressing an area of great need for which they are qualified? It is my understanding that optometrists are trying to become ophthalmologists. If that is their goal, why don?t they go to medical school? n
H. Dunbar Hoskins, Jr, MD, is AAO Executive Vice President. He may be reached at (415) 981-2020; [email protected].
1. Wall LL. What are the pros and cons of requiring postgraduate residency training as an entry level practice requirement? J Am Optom Assoc. 1992;63:783-786.
2. Bamber HM, Grenier EM, Harris MG. An evaluation of the US optometry school curricula. Optometric Education. 1998;23:41-47.
Optometry is trying to become ophthalmology, but by
taking major shortcuts in schooling.
H. Dunbar Hoskins, Jr, MD
Optometrists who now have the licensed right to perform laser eye surgery in Oklahoma may be able to perform the same procedure in any Department of Veteran Affairs (VA) hospital across the nation. A major problem associated with this ruling is that Oklahoma?s optometrists? surgical privileges have set a national standard. Even though Oklahoma is the only state that authorizes optometric laser surgery, the VA may allow those optometrists credentialed in Oklahoma to perform surgery throughout the country, regardless of their lack of medical schooling and preparation. Our veterans fought under the flag of the US, not the flag of Oklahoma. Why should they all be subject to the legislative vagaries of that state?
POLITICAL CLOUT
The optometry lobby at the state level continues to have a greater political influence than ophthalmology, and the former has used its power in rural states (where optometrists outnumber ophthalmologists 3:1) to achieve surgical privileges, as in Oklahoma. Optometrists will continue to use their political prowess to their regulatory advantage. It is expected that they will approach legislators in other states with the scenario, ?if we may perform surgery in the veterans? hospital in the VA system, we should be permitted to perform surgery in any state.?
Optometrists have had first-rate relationships with legislators for more than 50 years, and they have made significant contributions to legislators, thus making it difficult for legislators to refuse their requests. Legislators are passing optometric scope-of-practice expansion rulings with little understanding about what they are doing. Congresspersons do not have the time to gain a thorough understanding of each bill that crosses their desks, a situation leading them to trust the information provided by their political allies.
Doctors of medicine are governed by a natural law. It does not matter how much you plead, how big your donations are, or how much you argue on behalf of the patient; if you do not manage a disease correctly, or if the disease is overwhelming, the patient dies. You cannot dispute natural law.
Legislators and attorneys are governed by compromise and the ability to cajole, and they are influenced by dollars. Natural law does not play a role in their decision-making. Wannabe surgeons should obtain the privilege to perform surgery through education, training, and supervision, not argument, coaxing, and financial influence.
EDUCATION
Complex surgical procedures, such as laser eye surgery, require a concentration of experience and high-quality supervision during surgical preparation, performance, and postoperative follow-up. Only by completing medical school, fellowship, and residency (coupled with observing and performing numerous laser eye surgeries) will one achieve the skills of a surgeon. Optometrists should not perform surgery unless they finish medical school and all related academic training (eg, internship, fellowship, residency, etc.).
Unlike optometrists, ophthalmologists have 8 years of medical education, including surgical skills training and education on incisions and subsequent tissue reactions. That learning is the foundation for understanding medicine. A 90-minute workshop on a specific surgical procedure without this medical education does not constitute adequate training to perform a surgical procedure in humans. Two days are not enough, and neither are 4 months. Being a surgeon requires knowledge and experience that are only achieved through 8 years of medical training. To shortcut that process puts patients at risk. Patients need to ask themselves, ?Do I want someone performing the surgery who has the foundation of medical school, or do I want a 90-minute wonder?? Most patients do not know to ask this question, however, they assume someone in a white coat who calls himself ?doctor? has medical school training. That is not always true.
Although optometrists have tremendously expanded their scope of practice via legislative fiat over the last 10 years, no change has been made to the length of schooling necessary to become an optometrist. In 1992 and 1998, some leaders in optometric education stated, ?We are already stretched to our limits in providing education to our students,?1 and ?Expanding the scope of practice means expanding the curriculum, which is already bulging at the seams.?2 Optometry is expanding its scope of practice into the management of disease and the surgical realm without expanding its time for education and training. Intuitively, this situation just does not make sense.
VA SYSTEM
What has not been clearly defined is what the VA system means by ?supervision.? Ophthalmic organizations, such as the AAO, are waiting to see that term better delineated. It makes no sense for an ophthalmologist to observe an unqualified individual, such as an Oklahoma-licensed optometrist, perform a laser procedure for the first time in a state that itself does not permit such privileging. Would it not be fairer to the patient for the ophthalmologist, who has the time to supervise the procedure, to perform it himself?
There is no backlog of laser procedures in the VA system. The enormous backlog that exists is of refractions, optometry?s niche. Why do they want to move into areas for which they lack the medical training and experience instead of addressing an area of great need for which they are qualified? It is my understanding that optometrists are trying to become ophthalmologists. If that is their goal, why don?t they go to medical school? n
H. Dunbar Hoskins, Jr, MD, is AAO Executive Vice President. He may be reached at (415) 981-2020; [email protected].
1. Wall LL. What are the pros and cons of requiring postgraduate residency training as an entry level practice requirement? J Am Optom Assoc. 1992;63:783-786.
2. Bamber HM, Grenier EM, Harris MG. An evaluation of the US optometry school curricula. Optometric Education. 1998;23:41-47.
- Joined
- Jul 30, 2004
- Messages
- 102
- Reaction score
- 0
VA Optometric Surgery Campaign
A timeline of events demonstrates optometrists? efforts
to perform laser eye surgery.
By Michael Brennan, MD
This article describes the course of optometric scope-of-practice expansion related to the Veterans Health Administration (VHA) during the last 7 years. This piece is not intended to challenge surgery by nonsurgeons. The three salient events that frame this discussion of surgical intervention by nonsurgeons are featured, in addition to strategic and tactical outcomes. The strategies of nonphysician providers to shuttle between state legislative and federal regulatory authorities to enhance their licensing and privileging capabilities are illustrated, with a focus on the use of the Department of Veterans Affairs (VA) educational platform for optometric surgery. A critical assessment of the detriment to patient safety from nonphysician ophthalmic surgery is reserved for other authors.
1997 VHA OPTOMETRY
SERVICE GUIDELINES
The Optometry Service Guidelines for VHA Facilities, Handbook 1121.1, was released on October 23, 1997. The guidelines enabled optometrists to gain privileges for a vast range of invasive ophthalmic procedures, including both anterior and posterior segment laser surgery. Without federal legislative entitlement, established federal healthcare policy, or discussion in an open, multidisciplinary, professional forum, these guidelines formally allowed nonsurgeons the privilege of performing ophthalmic surgery. Because surgical education was not authorized in any optometry school due to the limits of state statutes, optometrists? entry into a nationwide VA educational system still required a single state breakthrough coupled with existent VA privileging policy that promoted federal jurisdiction over state restrictions.
Ophthalmology and a National Medical Coalition forced the VA Under Secretary for Health Affairs to rescind this handbook by March 31, 1998. Under questioning during a Senate VA Committee Hearing, the Under Secretary stated that optometrists would not be permitted to perform laser surgery in a VA facility. The subsequent Veterans Administration Eye Care Guide restored the credentialing and privileging capacity for optometrists to standard, nonphysician VA guidelines, summarized as follows. In the absence of overriding Veterans Administrating Central Office directives, local facility commanders are charged to consider the needs of the institution, as well as the issued state license capacity and competency of the nonphysician provider, to determine the limits of local VA facility privileging.
The leadership of the AAO and AMA substantially increased national attention on federal medical policy as dictated by the Veterans Administration Central Office. Within the domain of ophthalmology, Veterans Integrated Service Networks were upgraded to include an ophthalmology consultant, the Association of Veterans Administration Ophthalmologists became more actively engaged, and veteran service organizations, such as the VFW and American Legion, were challenged to speak for quality eye care.
Nonphysicians countered in state legislatures by markedly increasing the number of scope-of-practice initiatives for laser surgery and pharmaceutical privileges.
Indian Health Service and Military Service venues were pursued by limited-license providers, including optometrists and psychology, for national educational and practice opportunities that would be unrestricted by local (state) statute. Through aggressive state advocacy by ophthalmology and the medical community, laser surgical initiatives at the state level were resisted with one exception?Oklahoma.
OPTOMETRIC SURGERY IN OKLAHOMA
(November 1998)
In stark contrast to the VA scene where the optometric strike was silent, sudden, and almost subtle, the Oklahoma encounter lasted a decade and featured legislative and legal face-offs. Optometrists who had attended a laser surgery session at the annual AAO meeting began performing PRK and YAG capsulotomies at the Northeastern State University College of Optometry (Tahlequah, OK) in the mid-1990s, based on the assumption that a clause in the scope-of-practice statute permitted optometric laser surgery. Years later, the Optometric Board of Examiners finally ?certified? optometrists to perform anterior segment laser surgery. Legislative attempts to either sanction or disallow optometric laser surgery led to several legal encounters between the Oklahoma Board of Licensure (Medical Board) and the Oklahoma Board of Examiners in Optometry. In July 1997, the court issued a ruling prohibiting optometric laser surgery. Optometry redirected its efforts to political persuasion, and Senate Bill 11-92 was enacted, permitting laser surgery excluding retinal laser, LASIK, and cosmetic lid surgery. Noteworthy was the optometric campaign slogan, ?if it?s good enough for veterans, it?s good enough for Oklahomans,? which referred to the VA Optometry Service Guide mentioned earlier. In Oklahoma, relatively few optometrists were performing laser procedures and these in small numbers. Out-of-state optometrists, including several VA practitioners, became licensed in Oklahoma via weekend courses and board examinations. Included in the Northeastern State University College of Optometry?s advertisements were weekend courses for other opportunities, such as Botox injection (Allergan, Inc., Irvine, CA), advanced suturing, and excision of lid lesions.
ROBERT J. DOLE VA MEDICAL CENTER, WICHITA, KANSAS
(Spring 2003)
Armed with an Oklahoma license and certified for laser surgery, optometry approached the privileging systems of the VA. The Wichita VA Professional Standards Board granted privileges to an optometrist to perform laser and lid surgery, as compatible with VA nonphysician policy. Allowing nonphysicians to practice to the limit of their issued license, the VA vaulted the statutory authority of one state as an accepted practice for the entire nation.
The AAO?s response, fortified by a coalition including the AMA, the American College of Surgeons, the ASCRS, The American Academy of Family Physicians, and the American Osteopathic Association prompted the VA Under Secretary to enact a moratorium that suspended national optometry laser surgery privileges. The coalition later introduced House and Senate Bills defining ophthalmic surgery and restricting this practice to licensed MDs and DOs. The AAO?s Surgery by Surgeons campaign spread to veteran service organizations and national regulatory and licensure boards. The Veterans Administration Central Office reacted with the following directive.
VHA DIRECTIVE 2004-045
(August 24, 2004)
?It is Veterans Healthcare Administration (VHA) policy that optometrists are not to be granted clinical privileges to perform therapeutic laser eye procedures independently; they may be granted clinical privileges to perform such procedures under the supervision of an ophthalmologist, provided the optometrist?s state license statutes allow the performance of laser procedures, the optometrist has been fully trained, and the optometrist?s competency has been confirmed.?
As of press time, ophthalmology and optometry representatives were deliberating the issues of surgical supervision concerning obligation, proximity, liability, and informed consent. The House and Senate bills remain actively sponsored, awaiting VHA Central Office resolution.
CONCLUSION
Well stated by many of their political enthusiasts, optometry?s goal is a parallel profession rivaling ophthalmology. The optometry lobby felt it could force federal and state regulators and legislators to accept its arguments of access and affordability and capture surgical privileges. The lobby realized that optometric schools could not offer the essential surgical experience due to restrictive state statutes. This limitation forced the biphasic approach of seeking statutory and regulatory power, through isolated state and widespread federal venues, to expand scope of practice before requiring education and training that is comparable to what is required of ophthalmologists. This goal was accomplished via political persuasion both in Oklahoma and within the VHA Central Office. Opportunities for the advancement of optometry?s educational level exist in private ophthalmology practices, academic ophthalmology, and the Federal Health System. Many nonstandard, nonguaranteed ophthalmology relationships are currently accredited by the American Council on Optometric Education, but the Federal Health System offers the best solution for secondary optometric education. The VA, in contrast to the Military and Indian Health Services, offers the advantages of widespread national distribution, aggressive advancement of nonphysicians, and a well-recognized educational mission and environment.
By design and an extremely potent political presence, the Federal Medical System has become optometry?s surgical training venue. Two huge issues are before the Veterans Administration Central Office leadership: (1) must the Optometric Accreditation System for surgical education and training follow the same standards as the Accreditation Council for Graduate Medical Education; and (2) as the August 24, 2004, surgical ?supervision? directive becomes a reality, will ophthalmology be required to educate and certify optometry in the art and science of surgery?
The AAO and its coalition partners from the family of medicine will maintain a very close and continuous dialogue with the VA leadership. n
Michael Brennan, MD, is Secretariat for the AAO. He may be reached at (336) 228-0254; [email protected].
For a downloadable pdf of this article, including Tables and Figures, click here.
A timeline of events demonstrates optometrists? efforts
to perform laser eye surgery.
By Michael Brennan, MD
This article describes the course of optometric scope-of-practice expansion related to the Veterans Health Administration (VHA) during the last 7 years. This piece is not intended to challenge surgery by nonsurgeons. The three salient events that frame this discussion of surgical intervention by nonsurgeons are featured, in addition to strategic and tactical outcomes. The strategies of nonphysician providers to shuttle between state legislative and federal regulatory authorities to enhance their licensing and privileging capabilities are illustrated, with a focus on the use of the Department of Veterans Affairs (VA) educational platform for optometric surgery. A critical assessment of the detriment to patient safety from nonphysician ophthalmic surgery is reserved for other authors.
1997 VHA OPTOMETRY
SERVICE GUIDELINES
The Optometry Service Guidelines for VHA Facilities, Handbook 1121.1, was released on October 23, 1997. The guidelines enabled optometrists to gain privileges for a vast range of invasive ophthalmic procedures, including both anterior and posterior segment laser surgery. Without federal legislative entitlement, established federal healthcare policy, or discussion in an open, multidisciplinary, professional forum, these guidelines formally allowed nonsurgeons the privilege of performing ophthalmic surgery. Because surgical education was not authorized in any optometry school due to the limits of state statutes, optometrists? entry into a nationwide VA educational system still required a single state breakthrough coupled with existent VA privileging policy that promoted federal jurisdiction over state restrictions.
Ophthalmology and a National Medical Coalition forced the VA Under Secretary for Health Affairs to rescind this handbook by March 31, 1998. Under questioning during a Senate VA Committee Hearing, the Under Secretary stated that optometrists would not be permitted to perform laser surgery in a VA facility. The subsequent Veterans Administration Eye Care Guide restored the credentialing and privileging capacity for optometrists to standard, nonphysician VA guidelines, summarized as follows. In the absence of overriding Veterans Administrating Central Office directives, local facility commanders are charged to consider the needs of the institution, as well as the issued state license capacity and competency of the nonphysician provider, to determine the limits of local VA facility privileging.
The leadership of the AAO and AMA substantially increased national attention on federal medical policy as dictated by the Veterans Administration Central Office. Within the domain of ophthalmology, Veterans Integrated Service Networks were upgraded to include an ophthalmology consultant, the Association of Veterans Administration Ophthalmologists became more actively engaged, and veteran service organizations, such as the VFW and American Legion, were challenged to speak for quality eye care.
Nonphysicians countered in state legislatures by markedly increasing the number of scope-of-practice initiatives for laser surgery and pharmaceutical privileges.
Indian Health Service and Military Service venues were pursued by limited-license providers, including optometrists and psychology, for national educational and practice opportunities that would be unrestricted by local (state) statute. Through aggressive state advocacy by ophthalmology and the medical community, laser surgical initiatives at the state level were resisted with one exception?Oklahoma.
OPTOMETRIC SURGERY IN OKLAHOMA
(November 1998)
In stark contrast to the VA scene where the optometric strike was silent, sudden, and almost subtle, the Oklahoma encounter lasted a decade and featured legislative and legal face-offs. Optometrists who had attended a laser surgery session at the annual AAO meeting began performing PRK and YAG capsulotomies at the Northeastern State University College of Optometry (Tahlequah, OK) in the mid-1990s, based on the assumption that a clause in the scope-of-practice statute permitted optometric laser surgery. Years later, the Optometric Board of Examiners finally ?certified? optometrists to perform anterior segment laser surgery. Legislative attempts to either sanction or disallow optometric laser surgery led to several legal encounters between the Oklahoma Board of Licensure (Medical Board) and the Oklahoma Board of Examiners in Optometry. In July 1997, the court issued a ruling prohibiting optometric laser surgery. Optometry redirected its efforts to political persuasion, and Senate Bill 11-92 was enacted, permitting laser surgery excluding retinal laser, LASIK, and cosmetic lid surgery. Noteworthy was the optometric campaign slogan, ?if it?s good enough for veterans, it?s good enough for Oklahomans,? which referred to the VA Optometry Service Guide mentioned earlier. In Oklahoma, relatively few optometrists were performing laser procedures and these in small numbers. Out-of-state optometrists, including several VA practitioners, became licensed in Oklahoma via weekend courses and board examinations. Included in the Northeastern State University College of Optometry?s advertisements were weekend courses for other opportunities, such as Botox injection (Allergan, Inc., Irvine, CA), advanced suturing, and excision of lid lesions.
ROBERT J. DOLE VA MEDICAL CENTER, WICHITA, KANSAS
(Spring 2003)
Armed with an Oklahoma license and certified for laser surgery, optometry approached the privileging systems of the VA. The Wichita VA Professional Standards Board granted privileges to an optometrist to perform laser and lid surgery, as compatible with VA nonphysician policy. Allowing nonphysicians to practice to the limit of their issued license, the VA vaulted the statutory authority of one state as an accepted practice for the entire nation.
The AAO?s response, fortified by a coalition including the AMA, the American College of Surgeons, the ASCRS, The American Academy of Family Physicians, and the American Osteopathic Association prompted the VA Under Secretary to enact a moratorium that suspended national optometry laser surgery privileges. The coalition later introduced House and Senate Bills defining ophthalmic surgery and restricting this practice to licensed MDs and DOs. The AAO?s Surgery by Surgeons campaign spread to veteran service organizations and national regulatory and licensure boards. The Veterans Administration Central Office reacted with the following directive.
VHA DIRECTIVE 2004-045
(August 24, 2004)
?It is Veterans Healthcare Administration (VHA) policy that optometrists are not to be granted clinical privileges to perform therapeutic laser eye procedures independently; they may be granted clinical privileges to perform such procedures under the supervision of an ophthalmologist, provided the optometrist?s state license statutes allow the performance of laser procedures, the optometrist has been fully trained, and the optometrist?s competency has been confirmed.?
As of press time, ophthalmology and optometry representatives were deliberating the issues of surgical supervision concerning obligation, proximity, liability, and informed consent. The House and Senate bills remain actively sponsored, awaiting VHA Central Office resolution.
CONCLUSION
Well stated by many of their political enthusiasts, optometry?s goal is a parallel profession rivaling ophthalmology. The optometry lobby felt it could force federal and state regulators and legislators to accept its arguments of access and affordability and capture surgical privileges. The lobby realized that optometric schools could not offer the essential surgical experience due to restrictive state statutes. This limitation forced the biphasic approach of seeking statutory and regulatory power, through isolated state and widespread federal venues, to expand scope of practice before requiring education and training that is comparable to what is required of ophthalmologists. This goal was accomplished via political persuasion both in Oklahoma and within the VHA Central Office. Opportunities for the advancement of optometry?s educational level exist in private ophthalmology practices, academic ophthalmology, and the Federal Health System. Many nonstandard, nonguaranteed ophthalmology relationships are currently accredited by the American Council on Optometric Education, but the Federal Health System offers the best solution for secondary optometric education. The VA, in contrast to the Military and Indian Health Services, offers the advantages of widespread national distribution, aggressive advancement of nonphysicians, and a well-recognized educational mission and environment.
By design and an extremely potent political presence, the Federal Medical System has become optometry?s surgical training venue. Two huge issues are before the Veterans Administration Central Office leadership: (1) must the Optometric Accreditation System for surgical education and training follow the same standards as the Accreditation Council for Graduate Medical Education; and (2) as the August 24, 2004, surgical ?supervision? directive becomes a reality, will ophthalmology be required to educate and certify optometry in the art and science of surgery?
The AAO and its coalition partners from the family of medicine will maintain a very close and continuous dialogue with the VA leadership. n
Michael Brennan, MD, is Secretariat for the AAO. He may be reached at (336) 228-0254; [email protected].
For a downloadable pdf of this article, including Tables and Figures, click here.
- Joined
- Jul 30, 2004
- Messages
- 102
- Reaction score
- 0
An Ophthalmic Activist in Oklahoma
One ophthalmologist shares her thoughts on Oklahoma?s
scope-of-practice issues. An interview with Cynthia Bradford, MD.
By Sarah Nessler, Associate Editor, with Alicia Fagan, Senior Editor
TCRSToday: Could you give us a brief overview of the events that have led to the existing situation in Oklahoma between ophthalmology and optometry?
Dr. Bradford: In 1998, Oklahoma passed an unprecedented law allowing optometrists to perform laser surgery. They are trained in Oklahoma?s optometry school. This was the first huge step in an aggressive optometric lobbying effort in Oklahoma. In April of this year, Oklahoma passed a law that determined that the practice of optometry included nonlaser surgery, to be defined by rules promulgated by the Board of Optometry. The rules were declared by the board on October 4, 2004, and negotiations are ongoing. Oklahoma ophthalmologists are appealing to Governor Henry, who has promised not to allow the rules to expand optometry?s scope of practice. Oklahoma ophthalmologists are looking forward to Governor Henry?s keeping the rules on the straight and narrow.
Despite the recent legislation, the current state of affairs between ophthalmologists and optometrists in the state can hardly be described as static. Negotiations and organized activities are still taking place, and I do not consider the new optometric scope-of-practice expansion a done deal.
CRSToday: What is the Department of Veteran Affair?s role in optometric scope of practice?
Dr. Bradford: Physicians, nurses, dentists, as well as optometrists who are employed by the VA system have a different licensing requirement than those outside of that system. Within the VA, a physician?s state of licensure is independent of the facility and state. The VA system is structured to be able to move its employees from state to state. As a result, its nurses, dentists, and physicians all carry one license because, from an administrative and a logistical standpoint, it is too expensive and time-consuming to relicense these providers every time the VA moves them to another state. An optometrist who is licensed in Oklahoma to perform laser surgery could work for the VA in another state and perform laser surgery in that state under his Oklahoma license. The VA held a moratorium on this topic and subsequently issued a directive1 that has been updated several times. Its wording has been altered slightly, but the directive basically states that an optometrist can perform laser surgery within the VA system if his state of licensure allows it and if he has been both trained and credentialed. Additionally, the optometrist must perform the laser surgery under the supervision of an ophthalmologist.
This supervision required of ophthalmologists is not defined, which creates a very awkward situation for ophthalmologists who are licensed in a state where optometrists are not legally permitted to perform surgical procedures. There is a whole host of questions that arise from this directive. One example is, what is the physician supposed to do if he feels as though the procedure is not going well?
CRSToday: How did optometrists in Oklahoma gain surgical privileges in the first place?
Dr. Bradford: The 1998 laser bill that passed in Oklahoma read that optometrists were allowed to perform laser surgery, excluding retinal laser surgery, LASIK, and cosmetic lid surgery. In 2001, ophthalmologists in Oklahoma became aware that the state?s optometric school was teaching minor lid surgery, which entails cutting the eyelid with a blade. Attorneys who carefully reviewed the optometric statutes did not believe that optometrists had any statutory right to cut eyelids and remove lesions. Instructors at the optometric school were also teaching students pterygium management and how to deliver Botox (Allergan, Inc., Irvine, CA) injections. These factors contributed to a growing concern among the medical community that some optometrists in Oklahoma appeared to be overstepping their statutory rights.
CRSToday: What was Ophthalmology?s next move to address its concerns?
Dr. Bradford: At this point, activists within ophthalmology had to determine whether any optometrists were actually performing the procedures that they learned in the Oklahoma optometric school. Medicare billing records revealed that some optometrists were indeed billing for lid lesion removals, Botox injections, and quite a few other surgical codes. With evidence that the Oklahoma optometric school was teaching these procedures and that some optometrists were billing for them, ophthalmic activists asked Attorney General Drew Edmondson?s opinion about optometrists? explicit statutory rights and whether the Oklahoma State Board of Optometry were independent. They wanted to know whether the independence of the optometry board, which was established by law in 1999, simply allowed that board to set its own scope-of-practice standards.
Ophthalmic activists also verified that the Oklahoma Board of Optometry was not credentialing optometrists to perform lid surgery. Rather, they were credentialing their students to perform anterior segment surgery. They maintained two different categories of lasers: (1) optometrists credentialed to perform anterior segment surgery and (2) those credentialed to perform refractive surgery, who formed a smaller group. Absolutely no optometrists, however, were credentialed to perform eyelid surgery, interestingly. The Attorney General stated his opinion in March 2004 that (1) optometrists did not have the statutory right to cut eyelids, and (2) the Oklahoma State Optometric Board did not have the independence to decide scope of practice.
The optometrists believed the State Attorney General?s opinion on this issue interfered with their ability to practice because the CPT book of surgical codes included punctal occlusion, superficial corneal foreign body removal, and eyelash removal. Optometric activists? complaints to the Oklahoma state Attorney General about this issue resulted in an updated opinion2 on April 6, 2004, that clarified that the CPT codebook did not define surgery according to Oklahoma law. This statement transferred the issue of whether punctal plugs, lash removal, and corneal foreign body removal were surgery and would have allowed medical directors to deny optometrists those codes. These codes were never the issue, and it is likely that medical directors would not have denied these codes. The optometric activists did not resolve the issue with the medical directors, however. Because of their political clout, they simply went straight to the legislature and pushed for an overnight addition to pharmacy bill HB 2321 that gave them power over their own scope of practice, merely requiring the Oklahoma State Optometric Board to promulgate rules. In promoting the legislation, optometrists told the legislators that the attorney general?s opinion had unintended consquences that inhibited their practice and that they simply wanted the right to practice punctal plug insertion and removal, lash removal, and superficial corneal foreign body removal. They had the political power to do that because they have spent 30 years with grassroots politics.
(cont)
One ophthalmologist shares her thoughts on Oklahoma?s
scope-of-practice issues. An interview with Cynthia Bradford, MD.
By Sarah Nessler, Associate Editor, with Alicia Fagan, Senior Editor
TCRSToday: Could you give us a brief overview of the events that have led to the existing situation in Oklahoma between ophthalmology and optometry?
Dr. Bradford: In 1998, Oklahoma passed an unprecedented law allowing optometrists to perform laser surgery. They are trained in Oklahoma?s optometry school. This was the first huge step in an aggressive optometric lobbying effort in Oklahoma. In April of this year, Oklahoma passed a law that determined that the practice of optometry included nonlaser surgery, to be defined by rules promulgated by the Board of Optometry. The rules were declared by the board on October 4, 2004, and negotiations are ongoing. Oklahoma ophthalmologists are appealing to Governor Henry, who has promised not to allow the rules to expand optometry?s scope of practice. Oklahoma ophthalmologists are looking forward to Governor Henry?s keeping the rules on the straight and narrow.
Despite the recent legislation, the current state of affairs between ophthalmologists and optometrists in the state can hardly be described as static. Negotiations and organized activities are still taking place, and I do not consider the new optometric scope-of-practice expansion a done deal.
CRSToday: What is the Department of Veteran Affair?s role in optometric scope of practice?
Dr. Bradford: Physicians, nurses, dentists, as well as optometrists who are employed by the VA system have a different licensing requirement than those outside of that system. Within the VA, a physician?s state of licensure is independent of the facility and state. The VA system is structured to be able to move its employees from state to state. As a result, its nurses, dentists, and physicians all carry one license because, from an administrative and a logistical standpoint, it is too expensive and time-consuming to relicense these providers every time the VA moves them to another state. An optometrist who is licensed in Oklahoma to perform laser surgery could work for the VA in another state and perform laser surgery in that state under his Oklahoma license. The VA held a moratorium on this topic and subsequently issued a directive1 that has been updated several times. Its wording has been altered slightly, but the directive basically states that an optometrist can perform laser surgery within the VA system if his state of licensure allows it and if he has been both trained and credentialed. Additionally, the optometrist must perform the laser surgery under the supervision of an ophthalmologist.
This supervision required of ophthalmologists is not defined, which creates a very awkward situation for ophthalmologists who are licensed in a state where optometrists are not legally permitted to perform surgical procedures. There is a whole host of questions that arise from this directive. One example is, what is the physician supposed to do if he feels as though the procedure is not going well?
CRSToday: How did optometrists in Oklahoma gain surgical privileges in the first place?
Dr. Bradford: The 1998 laser bill that passed in Oklahoma read that optometrists were allowed to perform laser surgery, excluding retinal laser surgery, LASIK, and cosmetic lid surgery. In 2001, ophthalmologists in Oklahoma became aware that the state?s optometric school was teaching minor lid surgery, which entails cutting the eyelid with a blade. Attorneys who carefully reviewed the optometric statutes did not believe that optometrists had any statutory right to cut eyelids and remove lesions. Instructors at the optometric school were also teaching students pterygium management and how to deliver Botox (Allergan, Inc., Irvine, CA) injections. These factors contributed to a growing concern among the medical community that some optometrists in Oklahoma appeared to be overstepping their statutory rights.
CRSToday: What was Ophthalmology?s next move to address its concerns?
Dr. Bradford: At this point, activists within ophthalmology had to determine whether any optometrists were actually performing the procedures that they learned in the Oklahoma optometric school. Medicare billing records revealed that some optometrists were indeed billing for lid lesion removals, Botox injections, and quite a few other surgical codes. With evidence that the Oklahoma optometric school was teaching these procedures and that some optometrists were billing for them, ophthalmic activists asked Attorney General Drew Edmondson?s opinion about optometrists? explicit statutory rights and whether the Oklahoma State Board of Optometry were independent. They wanted to know whether the independence of the optometry board, which was established by law in 1999, simply allowed that board to set its own scope-of-practice standards.
Ophthalmic activists also verified that the Oklahoma Board of Optometry was not credentialing optometrists to perform lid surgery. Rather, they were credentialing their students to perform anterior segment surgery. They maintained two different categories of lasers: (1) optometrists credentialed to perform anterior segment surgery and (2) those credentialed to perform refractive surgery, who formed a smaller group. Absolutely no optometrists, however, were credentialed to perform eyelid surgery, interestingly. The Attorney General stated his opinion in March 2004 that (1) optometrists did not have the statutory right to cut eyelids, and (2) the Oklahoma State Optometric Board did not have the independence to decide scope of practice.
The optometrists believed the State Attorney General?s opinion on this issue interfered with their ability to practice because the CPT book of surgical codes included punctal occlusion, superficial corneal foreign body removal, and eyelash removal. Optometric activists? complaints to the Oklahoma state Attorney General about this issue resulted in an updated opinion2 on April 6, 2004, that clarified that the CPT codebook did not define surgery according to Oklahoma law. This statement transferred the issue of whether punctal plugs, lash removal, and corneal foreign body removal were surgery and would have allowed medical directors to deny optometrists those codes. These codes were never the issue, and it is likely that medical directors would not have denied these codes. The optometric activists did not resolve the issue with the medical directors, however. Because of their political clout, they simply went straight to the legislature and pushed for an overnight addition to pharmacy bill HB 2321 that gave them power over their own scope of practice, merely requiring the Oklahoma State Optometric Board to promulgate rules. In promoting the legislation, optometrists told the legislators that the attorney general?s opinion had unintended consquences that inhibited their practice and that they simply wanted the right to practice punctal plug insertion and removal, lash removal, and superficial corneal foreign body removal. They had the political power to do that because they have spent 30 years with grassroots politics.
(cont)
- Joined
- Jul 30, 2004
- Messages
- 102
- Reaction score
- 0
CRSToday: What, in your opinion, is optometry?s motivation for pursuing these laws?
Dr. Bradford: I cannot say what motivates anybody other than myself. Before HB 2321 was passed, however, I talked directly with the optometric activists and told them, if punctal plugs, lash epilation with forceps, and superficial corneal foreign body were the problem, that they could first address it directly with the medical directors. I was certain that medical directors would be willing to pay for those codes because they had historically done so. I suspect that all state ophthalmologists would agree that punctal plugs, lash removal, and foreign body removal are appropriate for optometrists to perform. The activists? response was that they did not trust ophthalmology and that they wanted to have a law. I thought that a law would be fine and proposed replacing the ambiguous wording with language that specifically listed punctal plugs, lash removal, and superficial corneal foreign bodies. I saw this compromise as in the best interest of both patients and providers. My proposal, however, was unacceptable to the optometrists. Why would a group turn down what it stated it needed? That is the current state of affairs, and I think that most people can draw their own conclusions.
CRSToday: Is the gray area encompassed within the term invasive surgery helping to blur the line in terms of optometric scope of practice?
Dr. Bradford: Is an injection invasive surgery? I feel that it is. As a general ophthalmologist, I see plenty of patients with retinal problems. Although I have access to photography in my building, I refer these patients to my retinal colleagues, as do most of the ophthalmologists I have encountered. The reason is that retinal treatments are much more sophisticated than they used to be. I personally do not think there is any reason for optometrists to perform fluorescein angiography. In another example, certain treatments for macular degeneration involve injecting medication into and around the eye. I feel that it is very dangerous to have laws on the book that allow nonphysicians to perform these injections. Similarly, I think Botox injections should be performed by a medical doctor.
CRSToday: What are your views on the argument of physician scarcity in certain states?
Dr. Bradford: Physician scarcity is not a problem in Oklahoma. The state is not huge, although it is rural. It is simply impossible to have an ophthalmologist in every small town, and patients who live in a rural setting understand that they must drive to the city for specialized care. They make this accommodation for a number of services. Complex ocular problems and surgery require care from a qualified medical professional. Simply legislating the privilege to perform certain procedures does not give less educated professionals the knowledge and ability to deliver that level of care. Access to a lower quality of care is not a reason to expand optometric scope of practice.
CRSToday: Is the percentage of practicing ODs who would like to gain surgical privileges higher than what optometric activists would have people believe?
Dr. Bradford: Optometrists generally say that they do not know any optometrists who want to perform these procedures. This may or may not be true, but there certainly is a small minority who want this right. I am sure that there are plenty of optometrists who never plan on performing laser surgery, but I have heard optometrists say that theirs is a legislated profession. They try to push the legislation so that the next generation has a greater scope of practice.
CRSToday: Some say that as many as 99.9% of optometrists in the US are not interested in pursuing surgical rights.
Dr. Bradford: Then you have to ask why they are so politically active. The requirements that ophthalmologists must fulfill to be board-certified have been so carefully outlined that it should not be questioned whether the entire length of training is necessary. It is not possible to shortcut the educational process and deliver the same quality of care. The public is not asking for lower standards of training. Our state?s youth are being told that they can bypass medical school, become certified in optometry in less time, and perform many of the same procedures that ophthalmologists do.
CRSToday: Why did ophthalmology?s efforts fall short in Oklahoma?
Dr. Bradford: Optometrists are very politically active, and especially so in Oklahoma. When you talk about optometry?s political power in Oklahoma, it is always remembered that a prior Speaker of the House taught optometrists to lobby and they learned well.
CRSToday: Are you pleased with the number of ophthalmologists who have become involved or are participating in fighting optometrists? attempts to broaden their scope of practice?
Dr. Bradford: No, I think ophthalmic participation should be 100% in Oklahoma, and, although it is much higher than in the past, it is not 100%. Optometrists could gain further privileges. It is very frustrating to try to educate legislators. Some have said to me that, although they know the right choice on the issue, they must still vote in favor of optometry. My only encouragement is that the legislature will be changing in Oklahoma soon as a result of term limits. I should note, however, that some very good legislators know the score and are willing to do what they think is right for patients.
CRSToday: What are the direct ramifications of the Oklahoma ruling on the rest of the country?
Dr. Bradford: What happened in Wisconsin in 2000 is a good example. Oklahoma optometrists visited optometrists in Wisconsin to teach them eyelid and laser surgery after the Board of Optometry in Wisconsin declared a ruling that optometrists could perform laser surgery. The Wisconsin optometric board received backlash from the legislature and the public and ultimately retracted that declaration.
CRSToday: What additional efforts have been made or are underway to broaden optometry?s scope of practice elsewhere?
Dr. Bradford: In North Carolina, the Board of Optometry has sued the Board of Medicine over injections. Similar legislation was introduced in New Jersey last year but failed. In some states, such as New York and Illinois, optometrists are trying to build ASCs at optometry schools. They want their students to perform all pre- and postoperative care, an effort I view as a foray into surgery. n
Cynthia Bradford, MD, currently serves as Secretary for State Affairs on the AAO?s Committee of Secretaries. She is Associate Professor of Ophthalmology at the Department of Ophthalmology at the University of Oklahoma Health Sciences Center/Dean A. McGee Eye Institute in Oklahoma City. Dr. Bradford may be reached at (405) 271-1819; [email protected].
1. Therapeutic Laser Eye Procedures. VHA Directive 2004-045 (2004). PDF file available at: http://www1.va.gov/vhapublications/ ViewPublication.asp?pub_ID=1148. Accessed: September 29, 2004.
2. Attorney General Opinion 04-9. PDF file available at: http://www.oklegal.onenet.net/oklegal-cgi/ifetch?okag+1270240066208+F. Accessed: September 29, 2004.
For a downloadable pdf of this article, including Tables and Figures, click here.
Dr. Bradford: I cannot say what motivates anybody other than myself. Before HB 2321 was passed, however, I talked directly with the optometric activists and told them, if punctal plugs, lash epilation with forceps, and superficial corneal foreign body were the problem, that they could first address it directly with the medical directors. I was certain that medical directors would be willing to pay for those codes because they had historically done so. I suspect that all state ophthalmologists would agree that punctal plugs, lash removal, and foreign body removal are appropriate for optometrists to perform. The activists? response was that they did not trust ophthalmology and that they wanted to have a law. I thought that a law would be fine and proposed replacing the ambiguous wording with language that specifically listed punctal plugs, lash removal, and superficial corneal foreign bodies. I saw this compromise as in the best interest of both patients and providers. My proposal, however, was unacceptable to the optometrists. Why would a group turn down what it stated it needed? That is the current state of affairs, and I think that most people can draw their own conclusions.
CRSToday: Is the gray area encompassed within the term invasive surgery helping to blur the line in terms of optometric scope of practice?
Dr. Bradford: Is an injection invasive surgery? I feel that it is. As a general ophthalmologist, I see plenty of patients with retinal problems. Although I have access to photography in my building, I refer these patients to my retinal colleagues, as do most of the ophthalmologists I have encountered. The reason is that retinal treatments are much more sophisticated than they used to be. I personally do not think there is any reason for optometrists to perform fluorescein angiography. In another example, certain treatments for macular degeneration involve injecting medication into and around the eye. I feel that it is very dangerous to have laws on the book that allow nonphysicians to perform these injections. Similarly, I think Botox injections should be performed by a medical doctor.
CRSToday: What are your views on the argument of physician scarcity in certain states?
Dr. Bradford: Physician scarcity is not a problem in Oklahoma. The state is not huge, although it is rural. It is simply impossible to have an ophthalmologist in every small town, and patients who live in a rural setting understand that they must drive to the city for specialized care. They make this accommodation for a number of services. Complex ocular problems and surgery require care from a qualified medical professional. Simply legislating the privilege to perform certain procedures does not give less educated professionals the knowledge and ability to deliver that level of care. Access to a lower quality of care is not a reason to expand optometric scope of practice.
CRSToday: Is the percentage of practicing ODs who would like to gain surgical privileges higher than what optometric activists would have people believe?
Dr. Bradford: Optometrists generally say that they do not know any optometrists who want to perform these procedures. This may or may not be true, but there certainly is a small minority who want this right. I am sure that there are plenty of optometrists who never plan on performing laser surgery, but I have heard optometrists say that theirs is a legislated profession. They try to push the legislation so that the next generation has a greater scope of practice.
CRSToday: Some say that as many as 99.9% of optometrists in the US are not interested in pursuing surgical rights.
Dr. Bradford: Then you have to ask why they are so politically active. The requirements that ophthalmologists must fulfill to be board-certified have been so carefully outlined that it should not be questioned whether the entire length of training is necessary. It is not possible to shortcut the educational process and deliver the same quality of care. The public is not asking for lower standards of training. Our state?s youth are being told that they can bypass medical school, become certified in optometry in less time, and perform many of the same procedures that ophthalmologists do.
CRSToday: Why did ophthalmology?s efforts fall short in Oklahoma?
Dr. Bradford: Optometrists are very politically active, and especially so in Oklahoma. When you talk about optometry?s political power in Oklahoma, it is always remembered that a prior Speaker of the House taught optometrists to lobby and they learned well.
CRSToday: Are you pleased with the number of ophthalmologists who have become involved or are participating in fighting optometrists? attempts to broaden their scope of practice?
Dr. Bradford: No, I think ophthalmic participation should be 100% in Oklahoma, and, although it is much higher than in the past, it is not 100%. Optometrists could gain further privileges. It is very frustrating to try to educate legislators. Some have said to me that, although they know the right choice on the issue, they must still vote in favor of optometry. My only encouragement is that the legislature will be changing in Oklahoma soon as a result of term limits. I should note, however, that some very good legislators know the score and are willing to do what they think is right for patients.
CRSToday: What are the direct ramifications of the Oklahoma ruling on the rest of the country?
Dr. Bradford: What happened in Wisconsin in 2000 is a good example. Oklahoma optometrists visited optometrists in Wisconsin to teach them eyelid and laser surgery after the Board of Optometry in Wisconsin declared a ruling that optometrists could perform laser surgery. The Wisconsin optometric board received backlash from the legislature and the public and ultimately retracted that declaration.
CRSToday: What additional efforts have been made or are underway to broaden optometry?s scope of practice elsewhere?
Dr. Bradford: In North Carolina, the Board of Optometry has sued the Board of Medicine over injections. Similar legislation was introduced in New Jersey last year but failed. In some states, such as New York and Illinois, optometrists are trying to build ASCs at optometry schools. They want their students to perform all pre- and postoperative care, an effort I view as a foray into surgery. n
Cynthia Bradford, MD, currently serves as Secretary for State Affairs on the AAO?s Committee of Secretaries. She is Associate Professor of Ophthalmology at the Department of Ophthalmology at the University of Oklahoma Health Sciences Center/Dean A. McGee Eye Institute in Oklahoma City. Dr. Bradford may be reached at (405) 271-1819; [email protected].
1. Therapeutic Laser Eye Procedures. VHA Directive 2004-045 (2004). PDF file available at: http://www1.va.gov/vhapublications/ ViewPublication.asp?pub_ID=1148. Accessed: September 29, 2004.
2. Attorney General Opinion 04-9. PDF file available at: http://www.oklegal.onenet.net/oklegal-cgi/ifetch?okag+1270240066208+F. Accessed: September 29, 2004.
For a downloadable pdf of this article, including Tables and Figures, click here.
- Joined
- Jul 30, 2004
- Messages
- 102
- Reaction score
- 0
Ethical Comanagement: an Oxymoron
As Sir Walter Scott once said, ?Oh, what a tangled web we weave,
when first we practice to deceive.?
By Ralph Lanciano, Jr, DO
As you peruse this edition of Cataract & Refractive Surgery Today and evaluate the responses and opinions of the AAO leadership and individual ophthalmologists and optometrists with respect to optometric surgical initiatives, the Oklahoma legislation, and the Department of Veterans Affairs (VA) situation, it becomes immediately apparent that optometry is changing from an allied health profession to a group that will soon be listing itself in a newly created section of the Yellow Pages, called Optometric Physicians and Surgeons.
You may also notice a curious term, ethical comanagement. Like the term comanagement, I fear that ethical comanagement may become cleverly woven into the literature as a way to legitimize the behavior of individuals who choose to skirt the guidelines established by the American College of Surgeons, AAO, ASCRS, and Association of University of Professors of Ophthalmology.
COMANAGEMENT
Abandoning Postoperative Care
During the several years leading up to the AAO/ASCRS Comanagement policy?s creation in 2000, the Council of the AAO repeatedly requested that the Board of Trustees address the issue that was plaguing state leadership: comanagement?s erosion of the underpinnings of ophthalmic care. Ophthalmologists were abdicating postoperative care for future referrals and avoiding political advocacy as an associated phenomenon.
The AAO?s Board of Trustees responded, and a nonbinding voluntary policy became a reality. The federal government, likewise, became concerned about the risks of financially induced kickbacks and established, through Stark Legislation (42 USCA 1395 NN and proposed 42 CFR 411 et seq.) and the Federal Fraud Abuse/Anti-Kickback Statutes (42 USCA 1320 A-7B), its definition of what it felt to be ?high-risk behavior? and that ?anything in cash or kind as an inducement to refer? is fraud. Intuitively, ophthalmologists knew that the agreement not to execute postoperative care themselves was ?the inducement to refer? (as long as it is unspoken, the coercion is unproven). Numerous articles appeared in the ophthalmic literature, including titles such as ?Comanagement Is Really No Management,?1 ?Comanagement, a Word Used to Hide Collusion,?2 ?Comanagement or Coercion,?3 and a thorough and exhaustive treatise by the Chairman of the AAO?s Ethics Committee, Samuel Packer, MD, entitled ?Ethics of Comanagement.?4
Who Takes Care of Whom and When?
The Centers for Medicare & Medicaid Services wrestled with establishing a uniform policy for the transfer of care. One of the most carefully written was the Kansas/Nebraska/Missouri Medicare Carriers payment policy for preoperative management, which states, ?Transfer of global surgical care will be allowed only to protect the legitimate interests of the beneficiaries in the following circumstances.? Legitimate indications were stated in the policy with no wiggle room. The term patient choice never appeared in the policy. Patrick Price, MD, from Kansas City, Missouri, author of the policy then restated the American College of Surgeons? position in Principles of Perioperative Responsibilities. It is based on and extracted from the AAO?s ethics policy, which asserts that the patient?s welfare and rights are placed above all other considerations.
No one has stated the issue more eloquently than one of the senior authors of the AAO comanagement position paper,5 Paul Orloff, MD, in his presentation to the Council following the unveiling of the policy at the Mid-Year Forum in 2000. Dr. Orloff said, ?I have never had a patient say to me, ?Dr. Orloff, you are a great surgeon, and I really like you, but after you do the surgery, I want to be taken care of by someone who is maybe a little less trained and [has] a little less experience, and I?d like to pay them a lot of money.? ?
Are we to believe that all of us can establish our own rules for the transfer of care for what we think is ethical? Is ?I?ve trained the optometrist, so I feel comfortable with his skill level? an acceptable defense for ethical comanagement? Who will judge whether an optometrist is adequately trained to handle the postoperative course? Sadly, the public has no idea that there is no uniform standard for this homemade observation, for we all know that, if there is any true management, it will be performed by the surgeons.
ODs IN THE va SYSTEM
The Executive Vice President of the American Board of Medical Specialties, Stephen H. Miller, MD, MPh, recently wrote a comprehensive letter6 to the Under Secretary for Health Policy Coordination at the VA that referred to the optometric privileging there. It stated, ?The Veterans Hospital Affairs directive is confusing, potentially initiates a two-tier system of eye care and may jeopardize the safety of patients undergoing laser surgery within the Veterans Hospital Affairs system. This was not an issue of professional turf, but an issue related to standards of educations, training, and quality of care provided by health professionals to patients.? He further stated, ?following completion of this training [ophthalmology residency], a candidate desiring to be a board certified ophthalmologist will be evaluated by an independent American Board of Medical Specialties member board according to generally accepted peer-reviewed standards and criteria. Thus, when an ophthalmologist performs laser eye surgery, the patient is assured that the person performing the surgery is not only technically capable of performing the procedure, but is also capable of judging which patients are appropriate candidates for the surgery [preoperative care], which patients have medical conditions that might contraindicate the surgery and is capable of independently dealing with any complications that may result from the surgery. Unless optometrists have undergone similar training and peer-reviewed evaluation, the patient cannot have the same assurance.? The point is the surgeon?s job is the surgeon?s job, only to be abdicated in unusual situations and only when it is clinically appropriate and in the patient?s best interest.
CONCLUSION
Why all the hubbub about comanagement now? If you listen to legislators who are sponsoring optometric surgical scope bills (which include laser surgery, incisional surgery, narcotics, oral medicines, and parenteral routes of administration), surgery is a natural evolution, considering the flagrant and cavalier transfer of pre- and postoperative care, also known as comanagement, to optometrists.
If you have to rationalize ethical decisions, they are probably unethical.
As Michel de Montaigne said, ?Easily doth the world deceive itself, in things it desireth or fain would have come to pass.?
Ralph Lanciano, Jr, DO, is Clinical Associate Professor at Scheie Institute, University of Pennsylvania, School of Medicine, Department of Ophthalmology, in Philadelphia. He is the past President of the New Jersey Academy of Ophthalmology. He may be reached at (856) 665-5533;
[email protected].
1. Weingeist T. How Comanagement Is Really no Management. EyeNet. 2000;4:1:11-12.
2. Spaeth GL. ?Comanagement?: a word used to hide collusion. Ophthalmic Surg Lasers. 1997;28:449-51.
3. Hoskins HD. Comanagement: Does the ?Co:? Stand for ?Cooperation? or ?Coercion?? EyeNet. 1999;3:8:14-15.
4. Packer S, Lynch J. Ethics of comanagement. Arch Ophthalmol. 2002;120(suppl 1):71-76.
5. Orloff P. AAO/ASCRS Joint Guidelines. Paper presented at: The AAO Mid-Year Forum; April 18, 2000; Chicago, IL.
6. Quoted from letter dated September 7, 2004, to Frances M. Murphy, MD, MPH, Deputy Under Secretary for Health for Health Policy Coordination, Department of Veteran Affairs, 810 Vermont Avenue NW (10H), Washington, DC 20420.
As Sir Walter Scott once said, ?Oh, what a tangled web we weave,
when first we practice to deceive.?
By Ralph Lanciano, Jr, DO
As you peruse this edition of Cataract & Refractive Surgery Today and evaluate the responses and opinions of the AAO leadership and individual ophthalmologists and optometrists with respect to optometric surgical initiatives, the Oklahoma legislation, and the Department of Veterans Affairs (VA) situation, it becomes immediately apparent that optometry is changing from an allied health profession to a group that will soon be listing itself in a newly created section of the Yellow Pages, called Optometric Physicians and Surgeons.
You may also notice a curious term, ethical comanagement. Like the term comanagement, I fear that ethical comanagement may become cleverly woven into the literature as a way to legitimize the behavior of individuals who choose to skirt the guidelines established by the American College of Surgeons, AAO, ASCRS, and Association of University of Professors of Ophthalmology.
COMANAGEMENT
Abandoning Postoperative Care
During the several years leading up to the AAO/ASCRS Comanagement policy?s creation in 2000, the Council of the AAO repeatedly requested that the Board of Trustees address the issue that was plaguing state leadership: comanagement?s erosion of the underpinnings of ophthalmic care. Ophthalmologists were abdicating postoperative care for future referrals and avoiding political advocacy as an associated phenomenon.
The AAO?s Board of Trustees responded, and a nonbinding voluntary policy became a reality. The federal government, likewise, became concerned about the risks of financially induced kickbacks and established, through Stark Legislation (42 USCA 1395 NN and proposed 42 CFR 411 et seq.) and the Federal Fraud Abuse/Anti-Kickback Statutes (42 USCA 1320 A-7B), its definition of what it felt to be ?high-risk behavior? and that ?anything in cash or kind as an inducement to refer? is fraud. Intuitively, ophthalmologists knew that the agreement not to execute postoperative care themselves was ?the inducement to refer? (as long as it is unspoken, the coercion is unproven). Numerous articles appeared in the ophthalmic literature, including titles such as ?Comanagement Is Really No Management,?1 ?Comanagement, a Word Used to Hide Collusion,?2 ?Comanagement or Coercion,?3 and a thorough and exhaustive treatise by the Chairman of the AAO?s Ethics Committee, Samuel Packer, MD, entitled ?Ethics of Comanagement.?4
Who Takes Care of Whom and When?
The Centers for Medicare & Medicaid Services wrestled with establishing a uniform policy for the transfer of care. One of the most carefully written was the Kansas/Nebraska/Missouri Medicare Carriers payment policy for preoperative management, which states, ?Transfer of global surgical care will be allowed only to protect the legitimate interests of the beneficiaries in the following circumstances.? Legitimate indications were stated in the policy with no wiggle room. The term patient choice never appeared in the policy. Patrick Price, MD, from Kansas City, Missouri, author of the policy then restated the American College of Surgeons? position in Principles of Perioperative Responsibilities. It is based on and extracted from the AAO?s ethics policy, which asserts that the patient?s welfare and rights are placed above all other considerations.
No one has stated the issue more eloquently than one of the senior authors of the AAO comanagement position paper,5 Paul Orloff, MD, in his presentation to the Council following the unveiling of the policy at the Mid-Year Forum in 2000. Dr. Orloff said, ?I have never had a patient say to me, ?Dr. Orloff, you are a great surgeon, and I really like you, but after you do the surgery, I want to be taken care of by someone who is maybe a little less trained and [has] a little less experience, and I?d like to pay them a lot of money.? ?
Are we to believe that all of us can establish our own rules for the transfer of care for what we think is ethical? Is ?I?ve trained the optometrist, so I feel comfortable with his skill level? an acceptable defense for ethical comanagement? Who will judge whether an optometrist is adequately trained to handle the postoperative course? Sadly, the public has no idea that there is no uniform standard for this homemade observation, for we all know that, if there is any true management, it will be performed by the surgeons.
ODs IN THE va SYSTEM
The Executive Vice President of the American Board of Medical Specialties, Stephen H. Miller, MD, MPh, recently wrote a comprehensive letter6 to the Under Secretary for Health Policy Coordination at the VA that referred to the optometric privileging there. It stated, ?The Veterans Hospital Affairs directive is confusing, potentially initiates a two-tier system of eye care and may jeopardize the safety of patients undergoing laser surgery within the Veterans Hospital Affairs system. This was not an issue of professional turf, but an issue related to standards of educations, training, and quality of care provided by health professionals to patients.? He further stated, ?following completion of this training [ophthalmology residency], a candidate desiring to be a board certified ophthalmologist will be evaluated by an independent American Board of Medical Specialties member board according to generally accepted peer-reviewed standards and criteria. Thus, when an ophthalmologist performs laser eye surgery, the patient is assured that the person performing the surgery is not only technically capable of performing the procedure, but is also capable of judging which patients are appropriate candidates for the surgery [preoperative care], which patients have medical conditions that might contraindicate the surgery and is capable of independently dealing with any complications that may result from the surgery. Unless optometrists have undergone similar training and peer-reviewed evaluation, the patient cannot have the same assurance.? The point is the surgeon?s job is the surgeon?s job, only to be abdicated in unusual situations and only when it is clinically appropriate and in the patient?s best interest.
CONCLUSION
Why all the hubbub about comanagement now? If you listen to legislators who are sponsoring optometric surgical scope bills (which include laser surgery, incisional surgery, narcotics, oral medicines, and parenteral routes of administration), surgery is a natural evolution, considering the flagrant and cavalier transfer of pre- and postoperative care, also known as comanagement, to optometrists.
If you have to rationalize ethical decisions, they are probably unethical.
As Michel de Montaigne said, ?Easily doth the world deceive itself, in things it desireth or fain would have come to pass.?
Ralph Lanciano, Jr, DO, is Clinical Associate Professor at Scheie Institute, University of Pennsylvania, School of Medicine, Department of Ophthalmology, in Philadelphia. He is the past President of the New Jersey Academy of Ophthalmology. He may be reached at (856) 665-5533;
[email protected].
1. Weingeist T. How Comanagement Is Really no Management. EyeNet. 2000;4:1:11-12.
2. Spaeth GL. ?Comanagement?: a word used to hide collusion. Ophthalmic Surg Lasers. 1997;28:449-51.
3. Hoskins HD. Comanagement: Does the ?Co:? Stand for ?Cooperation? or ?Coercion?? EyeNet. 1999;3:8:14-15.
4. Packer S, Lynch J. Ethics of comanagement. Arch Ophthalmol. 2002;120(suppl 1):71-76.
5. Orloff P. AAO/ASCRS Joint Guidelines. Paper presented at: The AAO Mid-Year Forum; April 18, 2000; Chicago, IL.
6. Quoted from letter dated September 7, 2004, to Frances M. Murphy, MD, MPH, Deputy Under Secretary for Health for Health Policy Coordination, Department of Veteran Affairs, 810 Vermont Avenue NW (10H), Washington, DC 20420.
- Joined
- Jul 30, 2004
- Messages
- 102
- Reaction score
- 0
Opinion: Ophthalmologists on Scope of Practice
Noted clinicians offer their thoughts on optometric scope-of-practice expansion.
By I. Howard Fine, MD; Lee T. Nordan, MD; Daniel S. Durrie, MD;
and Samuel Masket, MD
AI. Howard Fine, MD
Eugene, Oregon
I do not believe optometrists should perform any surgery under any circumstances. Optometrists receive book training on pathology, but they do not really understand pathologic physiology from first-hand experience gained from dealing with patients on an ongoing basis. Therefore, their ability to deliver postoperative care and manage intraoperative complications would be suboptimal. More importantly, ophthalmologists undergo a lengthy training process under the supervision of highly trained experts in order to develop adequate skills to consistently provide optimal care. I think optometrists who want to operate should attend medical school and complete a residency in ophthalmology.
Lee T. Nordan, MD
Carlsbad, California
My comments on the attempts of optometrists to perform ophthalmic surgery will not be particularly lengthy, but they should leave no doubt as to my position on the subject.
As stated by the National President of Vietnam Veterans of America,1 ?The [Veterans Administration] encourages [optometrists] to attend medical school and become ophthalmologists.? Anyone who believes that optometric training is a legitimate replacement for a medical school education and a 3-year ophthalmic residency in which medical school graduates are intensively trained in the techniques, complications, and difficult judgments associated with ocular surgery is, in my opinion, ignorant, delusional, or paid off.
All of the excellent optometrists with whom I have worked during the past 25 years quickly became impressed with the difficult treatment options posed by various situations that developed during surgery when a patient?s vision depended upon a surgeon?s skill and judgment. These practitioners readily admitted that they had neither the necessary training nor the capacity in the surgical arena and looked to me to treat the complications that had arisen. Is a 3-month training course going to provide an optometrist with sufficient surgical knowledge? By the same token, can ophthalmology legitimately defend a technician who places sutures during cataract extraction surgery (in the old days) at the conclusion of surgery or one who operates a laser that creates a LASIK flap? Eye surgery should be performed by eye surgeons, without exception.
For many years, California?s organized optometric group has been lobbying and conducting legal proceedings against an ophthalmologist?s right to perform refractions, claiming that ophthalmologists are not qualified to conduct such examinations. Optometry continues a campaign of turf warfare for political and financial reasons. These attempted forays into surgery by optometry have nothing to do with patient welfare. It makes me wonder what oath or altruistic goal is mumbled at the conclusion of optometric training. In fairness to most optometrists, I believe that these attempts to perform surgery are mainly a political gambit directed by a runaway leadership.
In recent years, the AAO and the ASCRS, as well as many of the state ophthalmic societies, have greatly improved their capacity to communicate with legislators. The battle against parasurgical professionals? desires to perform surgery in all of medicine will be very successful if the American public realizes the catastrophic consequences of lowering the standards for surgeons. However, any process involving the lay public at the grassroots level is very inefficient in the short term. This struggle must be waged at the political level, where money and power are the key ingredients.
The optometrists are very well organized politically and financially. Ophthalmology needs to continue improving its political and financial organization. Then, all ophthalmologists should join the fight big-time and thoroughly convince the legislators and the American public that the optometrists? desire to perform surgery is not in a patient?s best interest and would represent a restructuring of the ideals that all patients deserve the best possible medical care.
Daniel S. Durrie, MD
Kansas City, Missouri
I think that optometrists? and ophthalmologists? sharing in patient care has been very beneficial to patients. The optometrists generally know the patients very well because they have been treating them for years with glasses, contact lenses, and bifocals, and this information is quite helpful to the ophthalmologists with respect to surgical planning. Also, after the surgical process has been completed and the patient is discharged from the care of the surgeon, it is frequently more convenient for the patient to return to the optometrist for routine care.
Recently, there have been changes in the scope of optometric practice law in Oklahoma and questions about optometrists? ability to perform surgery in the Veterans Administration system. I think that, if a patient needs ocular surgery, his surgeon must be someone who has gone to medical school and completed an ophthalmology residency (7 years of training) to ensure that the patient receives the best possible care.
I am very disappointed that many of the leaders in optometry have not expressed publicly that they are not in favor of increasing the scope of practice for optometrists to include surgery, although they have said so to me personally. If this scope-of-practice expansion trend continues, ophthalmologists will have to look seriously at their participation in optometric education, perhaps including, at least for me, dropping the residency program for optometrists that I have run for 10 years. I think that many optometrists who are employees of ophthalmology clinics may be looking for jobs.
The line has been drawn, not by the doctors, but by what patients expect. Optometrists and ophthalmologists have had a relationship that has been built on what is best for patient care, and it does not include nonsurgeons? performing surgery. Patient care should continue to be the number-one priority.
(cont)
Noted clinicians offer their thoughts on optometric scope-of-practice expansion.
By I. Howard Fine, MD; Lee T. Nordan, MD; Daniel S. Durrie, MD;
and Samuel Masket, MD
AI. Howard Fine, MD
Eugene, Oregon
I do not believe optometrists should perform any surgery under any circumstances. Optometrists receive book training on pathology, but they do not really understand pathologic physiology from first-hand experience gained from dealing with patients on an ongoing basis. Therefore, their ability to deliver postoperative care and manage intraoperative complications would be suboptimal. More importantly, ophthalmologists undergo a lengthy training process under the supervision of highly trained experts in order to develop adequate skills to consistently provide optimal care. I think optometrists who want to operate should attend medical school and complete a residency in ophthalmology.
Lee T. Nordan, MD
Carlsbad, California
My comments on the attempts of optometrists to perform ophthalmic surgery will not be particularly lengthy, but they should leave no doubt as to my position on the subject.
As stated by the National President of Vietnam Veterans of America,1 ?The [Veterans Administration] encourages [optometrists] to attend medical school and become ophthalmologists.? Anyone who believes that optometric training is a legitimate replacement for a medical school education and a 3-year ophthalmic residency in which medical school graduates are intensively trained in the techniques, complications, and difficult judgments associated with ocular surgery is, in my opinion, ignorant, delusional, or paid off.
All of the excellent optometrists with whom I have worked during the past 25 years quickly became impressed with the difficult treatment options posed by various situations that developed during surgery when a patient?s vision depended upon a surgeon?s skill and judgment. These practitioners readily admitted that they had neither the necessary training nor the capacity in the surgical arena and looked to me to treat the complications that had arisen. Is a 3-month training course going to provide an optometrist with sufficient surgical knowledge? By the same token, can ophthalmology legitimately defend a technician who places sutures during cataract extraction surgery (in the old days) at the conclusion of surgery or one who operates a laser that creates a LASIK flap? Eye surgery should be performed by eye surgeons, without exception.
For many years, California?s organized optometric group has been lobbying and conducting legal proceedings against an ophthalmologist?s right to perform refractions, claiming that ophthalmologists are not qualified to conduct such examinations. Optometry continues a campaign of turf warfare for political and financial reasons. These attempted forays into surgery by optometry have nothing to do with patient welfare. It makes me wonder what oath or altruistic goal is mumbled at the conclusion of optometric training. In fairness to most optometrists, I believe that these attempts to perform surgery are mainly a political gambit directed by a runaway leadership.
In recent years, the AAO and the ASCRS, as well as many of the state ophthalmic societies, have greatly improved their capacity to communicate with legislators. The battle against parasurgical professionals? desires to perform surgery in all of medicine will be very successful if the American public realizes the catastrophic consequences of lowering the standards for surgeons. However, any process involving the lay public at the grassroots level is very inefficient in the short term. This struggle must be waged at the political level, where money and power are the key ingredients.
The optometrists are very well organized politically and financially. Ophthalmology needs to continue improving its political and financial organization. Then, all ophthalmologists should join the fight big-time and thoroughly convince the legislators and the American public that the optometrists? desire to perform surgery is not in a patient?s best interest and would represent a restructuring of the ideals that all patients deserve the best possible medical care.
Daniel S. Durrie, MD
Kansas City, Missouri
I think that optometrists? and ophthalmologists? sharing in patient care has been very beneficial to patients. The optometrists generally know the patients very well because they have been treating them for years with glasses, contact lenses, and bifocals, and this information is quite helpful to the ophthalmologists with respect to surgical planning. Also, after the surgical process has been completed and the patient is discharged from the care of the surgeon, it is frequently more convenient for the patient to return to the optometrist for routine care.
Recently, there have been changes in the scope of optometric practice law in Oklahoma and questions about optometrists? ability to perform surgery in the Veterans Administration system. I think that, if a patient needs ocular surgery, his surgeon must be someone who has gone to medical school and completed an ophthalmology residency (7 years of training) to ensure that the patient receives the best possible care.
I am very disappointed that many of the leaders in optometry have not expressed publicly that they are not in favor of increasing the scope of practice for optometrists to include surgery, although they have said so to me personally. If this scope-of-practice expansion trend continues, ophthalmologists will have to look seriously at their participation in optometric education, perhaps including, at least for me, dropping the residency program for optometrists that I have run for 10 years. I think that many optometrists who are employees of ophthalmology clinics may be looking for jobs.
The line has been drawn, not by the doctors, but by what patients expect. Optometrists and ophthalmologists have had a relationship that has been built on what is best for patient care, and it does not include nonsurgeons? performing surgery. Patient care should continue to be the number-one priority.
(cont)
- Joined
- Jul 30, 2004
- Messages
- 102
- Reaction score
- 0
Samuel Masket, MD
Los Angeles, California
On the surface, the question of whether Optometrists should have an expanded scope of practice to include surgery would appear to have a simple answer. Given that Optometrists are not medical doctors and have not attended medical school or a residency program that includes surgical training, it would seem obvious that they should not conduct surgery. However, there has been a trend in recent years that has allowed nonmedical practitioners to gain broader privileges through legislation; this has occurred in Ophthalmology as well as other areas of medical care. To me, the most interesting aspect of these scope-of-practice expansions is that, in certain states (Oklahoma is a prime example), optometrists have had the opportunity to determine their own scope of practice, which now permits them to practice eye surgery. Optometrists in that state have self-governance and are not overseen by the state medical or surgical boards, but rather by state optometric boards. On the other hand, I sense that all providers of surgery should be under the jurisdiction of the state boards for medicine and surgery.
Optometrists have gained a broader scope of practice through strong lobbying activity at the state level. State ophthalmological societies, by contrast, are hindered by an average membership rate of 50% and are typically underfunded. Ophthalmology has historically organized strongly at the national level for other areas of advocacy such as reimbursement and regulation, but has not been as effective in working with state legislatures. This so-called battle over optometric scope of practice is being fought in the state legislatures, where optometrists outnumber ophthalmologists by roughly 2:1 and tend to be more aggressive in their efforts. Furthermore, optometrists have, perhaps, partly achieved these scope-of-practice gains by participating in medical education programs?a fact that they use in conversations with state legislators. They argue that this knowledge base, in combination with comanagement experience, should enable them to provide the same level of care as ophthalmologists. The essential question is whether or not there are negative public health effects of optometric scope-of-practice expansion. Unless organized ophthalmology is successful with lobbying at the state level, which is very costly, I foresee that the optometric scope-of-practice expansion trend will continue, particularly in rural states where geography plays a role in the delivery of care.
Additionally, there is the question of the lay public?s understanding of the current differences between the specialties. Although the AAO has made concerted efforts to distinguish ophthalmologists from optometrists by creating the Eye M.D. logo, it is remarkable that the lay public still has a poor understanding of the distinction between the two professions. Many people do not understand that the ophthalmologist has gone through medical school and is specifically trained to provide general medical care as well as medical and surgical care of the eye.
For the far-reaching future, I sense that we will probably see a merger of the disciplines, perhaps beginning in the form of a common basic education. Those interested in providing primary eye will then do so, and those interested in providing surgical care may follow that pursuit with additional training. The ultimate merger of the specialties, with attention to work force needs, would benefit the quality of patient care, because individuals would be able to pursue their primary interest.
I. Howard Fine, MD, is Clinical Professor of Ophthalmology at the Casey Eye Institute at Oregon Health & Science University in Portland and is in clinical practice with Drs. Fine, Hoffman & Packer, LLC in Eugene, Oregon. Dr. Fine may be reached at (541) 687-2110; [email protected].
Lee T. Nordan, MD, is a technology consultant for Vision Membrane Technologies, Inc. Dr. Nordan may be reached at (760) 431-1846; [email protected].
Daniel S. Durrie, MD, is Director of Durrie Vision in Overland Park, Kansas, and is Clinical Assistant Professor of Ophthalmology at the Kansas University Medical Center in Kansas City, Kansas. Dr. Durrie may be reached at (913) 497-3737; [email protected].
Samuel Masket, MD, is in private practice in Los Angeles and is Clinical Professor of Ophthalmology at UCLA. Dr. Masket may be reached at (310) 229-1220;
[email protected].
1. Academy Express. American Academy of Ophthalmology. 2004;3:31.
For a downloadable pdf of this article, including Tables and Figures, click here.
Los Angeles, California
On the surface, the question of whether Optometrists should have an expanded scope of practice to include surgery would appear to have a simple answer. Given that Optometrists are not medical doctors and have not attended medical school or a residency program that includes surgical training, it would seem obvious that they should not conduct surgery. However, there has been a trend in recent years that has allowed nonmedical practitioners to gain broader privileges through legislation; this has occurred in Ophthalmology as well as other areas of medical care. To me, the most interesting aspect of these scope-of-practice expansions is that, in certain states (Oklahoma is a prime example), optometrists have had the opportunity to determine their own scope of practice, which now permits them to practice eye surgery. Optometrists in that state have self-governance and are not overseen by the state medical or surgical boards, but rather by state optometric boards. On the other hand, I sense that all providers of surgery should be under the jurisdiction of the state boards for medicine and surgery.
Optometrists have gained a broader scope of practice through strong lobbying activity at the state level. State ophthalmological societies, by contrast, are hindered by an average membership rate of 50% and are typically underfunded. Ophthalmology has historically organized strongly at the national level for other areas of advocacy such as reimbursement and regulation, but has not been as effective in working with state legislatures. This so-called battle over optometric scope of practice is being fought in the state legislatures, where optometrists outnumber ophthalmologists by roughly 2:1 and tend to be more aggressive in their efforts. Furthermore, optometrists have, perhaps, partly achieved these scope-of-practice gains by participating in medical education programs?a fact that they use in conversations with state legislators. They argue that this knowledge base, in combination with comanagement experience, should enable them to provide the same level of care as ophthalmologists. The essential question is whether or not there are negative public health effects of optometric scope-of-practice expansion. Unless organized ophthalmology is successful with lobbying at the state level, which is very costly, I foresee that the optometric scope-of-practice expansion trend will continue, particularly in rural states where geography plays a role in the delivery of care.
Additionally, there is the question of the lay public?s understanding of the current differences between the specialties. Although the AAO has made concerted efforts to distinguish ophthalmologists from optometrists by creating the Eye M.D. logo, it is remarkable that the lay public still has a poor understanding of the distinction between the two professions. Many people do not understand that the ophthalmologist has gone through medical school and is specifically trained to provide general medical care as well as medical and surgical care of the eye.
For the far-reaching future, I sense that we will probably see a merger of the disciplines, perhaps beginning in the form of a common basic education. Those interested in providing primary eye will then do so, and those interested in providing surgical care may follow that pursuit with additional training. The ultimate merger of the specialties, with attention to work force needs, would benefit the quality of patient care, because individuals would be able to pursue their primary interest.
I. Howard Fine, MD, is Clinical Professor of Ophthalmology at the Casey Eye Institute at Oregon Health & Science University in Portland and is in clinical practice with Drs. Fine, Hoffman & Packer, LLC in Eugene, Oregon. Dr. Fine may be reached at (541) 687-2110; [email protected].
Lee T. Nordan, MD, is a technology consultant for Vision Membrane Technologies, Inc. Dr. Nordan may be reached at (760) 431-1846; [email protected].
Daniel S. Durrie, MD, is Director of Durrie Vision in Overland Park, Kansas, and is Clinical Assistant Professor of Ophthalmology at the Kansas University Medical Center in Kansas City, Kansas. Dr. Durrie may be reached at (913) 497-3737; [email protected].
Samuel Masket, MD, is in private practice in Los Angeles and is Clinical Professor of Ophthalmology at UCLA. Dr. Masket may be reached at (310) 229-1220;
[email protected].
1. Academy Express. American Academy of Ophthalmology. 2004;3:31.
For a downloadable pdf of this article, including Tables and Figures, click here.
- Joined
- Jul 30, 2004
- Messages
- 102
- Reaction score
- 0
ISRS/AAO?s Perspective on the OD/MD Struggle
The organization?s chairperson weighs in on efforts by legislative
lobbies and recent restrictions on meeting attendance.
By James J. Salz, MD
The partial ban on optometric attendance at the AAO?s annual meeting (followed recently by a similar measure from the ASCRS) is a tender subject for both optometrists and ophthalmologists. Although many of us supported optometrists in their request to prescribe antibiotics, ophthalmologists as a whole are deeply upset by the optometry lobby?s aggressive pursuit of surgical privileges. A concern was that optometrists might use course attendance to bolster their legislative efforts for these privileges. The ISRS supports the AAO?s and ASCRS? decisions to limit optometric attendance at their meetings. The ultimate effect of these moves cannot now be known, but they will certainly cause some hard feelings. This article summarizes my view of the issues in play and of the action needed for the future.
MEDICAL TRAINING
Worth noting is that a certain level of background training is assumed of AAO course participants. Specifically, individuals are expected to have completed medical school, an internship, 3 years of residency training, and, in some cases, 1 or 2 years of fellowship training. If optometrists wish to be trained to perform surgical procedures, they may attend medical school, and some have done just that. To obtain surgical privileges by legislative edict, in my opinion, is unfair to the public. Ophthalmologists have the necessary training in anatomy and basic science as well as hands-on experience with a high volume of surgical cases. A physician must see a lot of pathology in order to differentiate between an inflammatory reaction in the cornea, such as diffuse lamellar keratitis, and an infectious process.
WORKING TOGETHER
The AAO, ISRS, and ASCRS have all published guidelines on the ethical comanagement of refractive surgery patients. Many refractive surgeons engage in some level of comanagement. I comanage some patients with optometrists, and I am confident that they will perform accurate refractions as well as preoperative examinations and that they will refer patients back when they are having problems. Most of the optometrists with whom I have talked do not desire to perform surgery, but they do need to understand the basics of the procedures. I have given seminars on wavefront technology to optometrists who work with me or the center where I practice. It is important for them to be up to date on the latest techniques and technology so that they may, for example, differentiate between good and poor candidates for wavefront-guided laser procedures.
MOVING FORWARD
Ophthalmologists? active and monetary support of their societies is needed. Members of the ISRS? executive committee have all made significant financial donations in support of the Surgical Scope Fund. AAO and ISRS members are encouraged to make contributions as well through the AAO?s Washington, DC, office.
The optometry lobby has always been better organized and more active compared with the ophthalmology lobby. We must act to counter efforts to expand the optometric scope of practice. The situation in Oklahoma was a red flag. Optometrists can become licensed in that state and now perform surgical procedures at VA hospitals under the supervision of an ophthalmologist (the terms of this supervision are unclear). Potentially, optometrists could then argue that, if the surgical care they provide to this country?s veterans is adequate, then why may they not operate on the citizens of the remaining
49 states? This argument would be difficult for state legislators to refute, particularly if they do not understand the difference between ophthalmologists, optometrists, and opticians. Ophthalmologists must work to educate legislators and the public on this score.
CONCLUSION
Unfortunately, the partial bans on optometric attendance at the AAO and ASCRS annual meetings will prevent some optometrists from delivering presentations on optics, refractions, contact lens fittings, and even wavefront studies. It was time, however, for these ophthalmic organizations to take a stand in the current struggle. To paraphrase a comment made by Richard Lindstrom, MD, at the Storm Eye/ASCRS Clinical Update 2004, ?It is time to draw a line in the sand.?
James J. Salz, MD, is Clinical Professor, Ophthalmology, University of Southern California, Los Angeles, and is Chairperson of the ISRS/
AAO. Dr. Salz may be reached at (323) 653-3800; [email protected].
For a downloadable pdf of this article, including Tables and Figures, click here.
The organization?s chairperson weighs in on efforts by legislative
lobbies and recent restrictions on meeting attendance.
By James J. Salz, MD
The partial ban on optometric attendance at the AAO?s annual meeting (followed recently by a similar measure from the ASCRS) is a tender subject for both optometrists and ophthalmologists. Although many of us supported optometrists in their request to prescribe antibiotics, ophthalmologists as a whole are deeply upset by the optometry lobby?s aggressive pursuit of surgical privileges. A concern was that optometrists might use course attendance to bolster their legislative efforts for these privileges. The ISRS supports the AAO?s and ASCRS? decisions to limit optometric attendance at their meetings. The ultimate effect of these moves cannot now be known, but they will certainly cause some hard feelings. This article summarizes my view of the issues in play and of the action needed for the future.
MEDICAL TRAINING
Worth noting is that a certain level of background training is assumed of AAO course participants. Specifically, individuals are expected to have completed medical school, an internship, 3 years of residency training, and, in some cases, 1 or 2 years of fellowship training. If optometrists wish to be trained to perform surgical procedures, they may attend medical school, and some have done just that. To obtain surgical privileges by legislative edict, in my opinion, is unfair to the public. Ophthalmologists have the necessary training in anatomy and basic science as well as hands-on experience with a high volume of surgical cases. A physician must see a lot of pathology in order to differentiate between an inflammatory reaction in the cornea, such as diffuse lamellar keratitis, and an infectious process.
WORKING TOGETHER
The AAO, ISRS, and ASCRS have all published guidelines on the ethical comanagement of refractive surgery patients. Many refractive surgeons engage in some level of comanagement. I comanage some patients with optometrists, and I am confident that they will perform accurate refractions as well as preoperative examinations and that they will refer patients back when they are having problems. Most of the optometrists with whom I have talked do not desire to perform surgery, but they do need to understand the basics of the procedures. I have given seminars on wavefront technology to optometrists who work with me or the center where I practice. It is important for them to be up to date on the latest techniques and technology so that they may, for example, differentiate between good and poor candidates for wavefront-guided laser procedures.
MOVING FORWARD
Ophthalmologists? active and monetary support of their societies is needed. Members of the ISRS? executive committee have all made significant financial donations in support of the Surgical Scope Fund. AAO and ISRS members are encouraged to make contributions as well through the AAO?s Washington, DC, office.
The optometry lobby has always been better organized and more active compared with the ophthalmology lobby. We must act to counter efforts to expand the optometric scope of practice. The situation in Oklahoma was a red flag. Optometrists can become licensed in that state and now perform surgical procedures at VA hospitals under the supervision of an ophthalmologist (the terms of this supervision are unclear). Potentially, optometrists could then argue that, if the surgical care they provide to this country?s veterans is adequate, then why may they not operate on the citizens of the remaining
49 states? This argument would be difficult for state legislators to refute, particularly if they do not understand the difference between ophthalmologists, optometrists, and opticians. Ophthalmologists must work to educate legislators and the public on this score.
CONCLUSION
Unfortunately, the partial bans on optometric attendance at the AAO and ASCRS annual meetings will prevent some optometrists from delivering presentations on optics, refractions, contact lens fittings, and even wavefront studies. It was time, however, for these ophthalmic organizations to take a stand in the current struggle. To paraphrase a comment made by Richard Lindstrom, MD, at the Storm Eye/ASCRS Clinical Update 2004, ?It is time to draw a line in the sand.?
James J. Salz, MD, is Clinical Professor, Ophthalmology, University of Southern California, Los Angeles, and is Chairperson of the ISRS/
AAO. Dr. Salz may be reached at (323) 653-3800; [email protected].
For a downloadable pdf of this article, including Tables and Figures, click here.
- Joined
- Jul 30, 2004
- Messages
- 102
- Reaction score
- 0
Political Ophthalmology 101
Turning physicians into activists.
By Ralph Lanciano, Jr, DO
No one is watching you read this article, so take a very short moment and honestly answer these questions: (1) Why haven?t I ever met with a state legislator? and (2) why do I not contribute money to my state?s ophthalmology political action committee (PAC)? If you are like 70% or more of your fellow ophthalmologists, you have never gotten politically involved.
There are lots of knee-jerk answers people give when asked to call a legislator: they are too busy; they do not like or trust politicians; or the problem is someone else?s. Those who do get involved politically worry about who will find out and what the economic consequences may be. Although these are all reasonable responses, they are not without a valid retort.
MDs? LOBBYING LABORS
Improving Efforts via Positive Actions
When you look at issues such as lifting the ban on assault weapons and the recent repeal of the bill in Pennsylvania that mandated helmets for motorcycle drivers, you can certainly lose faith in the political system?s being grounded in common sense and logic. Therefore, it is not surprising that an issue such as eye surgery?s being performed by individuals who have not completed medical school becomes a legislative reality. Having lost recent legislative battles in my own state of New Jersey, I am often asked why ophthalmology seems to be losing so many political disputes despite the fact that, in all good sense and logic, it is on the right side of the issues.
Lobbying, in some form, has been an honored specialty of the political system. Whether it is the AMA, the AAO, or state specialty societies, organized medicine uses the lobby to represent its interests, as does any other special interest group. Optometry uses a lobby to represent its perspective but appears to have a more carefully planned strategy than the aforementioned organizations. Essentially, optometry is organizing toward ?yes,? and ophthalmology is organizing toward ?no.? It is much easier to get people involved if you ask them to do something positive that will improve their lot. Optometry, by attempting to advance its scope of practice, has everything to gain and nothing to lose. However, the losers will be the unsuspecting patients who chose to see an optometrist and are unaware of the practitioner?s lack of extensive clinical training as well as the absence of protection this affords patients.
It is hard to ask people to become active in an effort that could appear to be self-serving. Organized optometry had a major coup de guerre when it characterized the impending contests between ophthalmologists and optometrists as a ?turf battle.? There is not a media source around that has not used that terminology to describe ophthalmology?s effort to halt optometry?s legislative expansions. The fact is that, although the economics of this issue are important, ophthalmologists have often failed miserably to communicate that our positions are in the patients? best interest and are based on our valuation of thorough medical, surgical, and clinical education.
Lobbying Rewards
The optometric lobby has had many distinct advantages. It is heavily funded by a group of optometrists, all of whom believe in its mission. While in school, optometrists learn about the ultimate benefit of grassroots activities. Nearly every optometrist decides to play some role and make some contribution politically. Dollars are only part of the picture. Politicians respond to their constituents, votes, and interests. Helping the politician to become elected or re-elected is no small part of the process. Continuously hammering away at issues enforces the ?sincerity? of the optometrists? position. Optometrists are tireless and tenacious, and they show up with their dollars.
The optometric associations? members are available, on short notice, to appear at legislators? offices, in legislative committee hearings, or at fundraisers. They also have a constant presence in the halls of the state houses. Legislators actually know most of the political optometric leaders.
OPHTHALMOLOGY?S POLITICAL ROLE
Because ophthalmologists are busy doing the job for which they were trained in medical school, they are often unable to shuffle or reschedule patients when called upon on short notice. Still, there is always time to squeeze in something important. Maybe you are not the ophthalmologist to ask to show up in the state capitol on 2 days? notice, but you certainly can call, write to, or make an appointment to visit a legislator during your planned free time. You could attend a legislator?s fundraiser and meet other constituents from your district. I cannot overemphasize how important it is that a legislator recognize your face and name and know that you are available, if needed, to answer his questions on health issues. Your state ophthalmologic society can send you reams of information that you can communicate to legislators regarding issues of pertinence to ophthalmology.
IS MEDICAL SCHOOL A MYTH?
Optometrists? first successes ultimately began when diagnostic drugs were approved throughout the states. The huge issue of Therapeutic Practice Acts expansion transformed optometry from an optical science to an allied health profession and allowed the optometric lobby to start on a trail of diagnosis and subsequent medical (and now surgical) treatment. The Therapeutic Practice Acts, although varied in scope, have broadened optometric scope of practice nationwide, starting with topicals, moving to oral medicines, followed by narcotics and an anomalous debacle in Oklahoma with laser therapy in 1998, and culminating in incisional surgical privileging in 2004. Optometry was ostensibly based on the optical sciences; it was never intended to intrude into the practice of medicine. Yet, as time passed, optometrists? philosophy has changed. They decided that they wanted the ophthalmologist?s degree without the clinical education, medical school internship, and residency. In an editorial, a past president of the New Jersey Optometric Association referred to medical school as a myth: ?You don?t have to go to medical school to be a physician.?1 In New Jersey and other states, optometrists now advertise themselves as optometric physicians. What can we expect the public to think, when many graduates of medical schools do not know the difference between an optometrist and an ophthalmologist?
MANAGED CARE
How can ophthalmology have allowed the managed care industry to commit to the specious logic that optometrists are better gatekeepers for managed eye care because they are less expensive and know more about eye care than primary care physicians? This happened in part because ophthalmologists were busy with patients, and because most ophthalmologists and medical doctors have little or no training in business management, interpersonal relationships, or any other area needed to negotiate with a managed-care company, a lawyer, or a legislator. Optometry has reinforced the value of camping on the doorstep of decision makers. The statement, ?the absent are always in the wrong,? applied in this case.
(cont)
Turning physicians into activists.
By Ralph Lanciano, Jr, DO
No one is watching you read this article, so take a very short moment and honestly answer these questions: (1) Why haven?t I ever met with a state legislator? and (2) why do I not contribute money to my state?s ophthalmology political action committee (PAC)? If you are like 70% or more of your fellow ophthalmologists, you have never gotten politically involved.
There are lots of knee-jerk answers people give when asked to call a legislator: they are too busy; they do not like or trust politicians; or the problem is someone else?s. Those who do get involved politically worry about who will find out and what the economic consequences may be. Although these are all reasonable responses, they are not without a valid retort.
MDs? LOBBYING LABORS
Improving Efforts via Positive Actions
When you look at issues such as lifting the ban on assault weapons and the recent repeal of the bill in Pennsylvania that mandated helmets for motorcycle drivers, you can certainly lose faith in the political system?s being grounded in common sense and logic. Therefore, it is not surprising that an issue such as eye surgery?s being performed by individuals who have not completed medical school becomes a legislative reality. Having lost recent legislative battles in my own state of New Jersey, I am often asked why ophthalmology seems to be losing so many political disputes despite the fact that, in all good sense and logic, it is on the right side of the issues.
Lobbying, in some form, has been an honored specialty of the political system. Whether it is the AMA, the AAO, or state specialty societies, organized medicine uses the lobby to represent its interests, as does any other special interest group. Optometry uses a lobby to represent its perspective but appears to have a more carefully planned strategy than the aforementioned organizations. Essentially, optometry is organizing toward ?yes,? and ophthalmology is organizing toward ?no.? It is much easier to get people involved if you ask them to do something positive that will improve their lot. Optometry, by attempting to advance its scope of practice, has everything to gain and nothing to lose. However, the losers will be the unsuspecting patients who chose to see an optometrist and are unaware of the practitioner?s lack of extensive clinical training as well as the absence of protection this affords patients.
It is hard to ask people to become active in an effort that could appear to be self-serving. Organized optometry had a major coup de guerre when it characterized the impending contests between ophthalmologists and optometrists as a ?turf battle.? There is not a media source around that has not used that terminology to describe ophthalmology?s effort to halt optometry?s legislative expansions. The fact is that, although the economics of this issue are important, ophthalmologists have often failed miserably to communicate that our positions are in the patients? best interest and are based on our valuation of thorough medical, surgical, and clinical education.
Lobbying Rewards
The optometric lobby has had many distinct advantages. It is heavily funded by a group of optometrists, all of whom believe in its mission. While in school, optometrists learn about the ultimate benefit of grassroots activities. Nearly every optometrist decides to play some role and make some contribution politically. Dollars are only part of the picture. Politicians respond to their constituents, votes, and interests. Helping the politician to become elected or re-elected is no small part of the process. Continuously hammering away at issues enforces the ?sincerity? of the optometrists? position. Optometrists are tireless and tenacious, and they show up with their dollars.
The optometric associations? members are available, on short notice, to appear at legislators? offices, in legislative committee hearings, or at fundraisers. They also have a constant presence in the halls of the state houses. Legislators actually know most of the political optometric leaders.
OPHTHALMOLOGY?S POLITICAL ROLE
Because ophthalmologists are busy doing the job for which they were trained in medical school, they are often unable to shuffle or reschedule patients when called upon on short notice. Still, there is always time to squeeze in something important. Maybe you are not the ophthalmologist to ask to show up in the state capitol on 2 days? notice, but you certainly can call, write to, or make an appointment to visit a legislator during your planned free time. You could attend a legislator?s fundraiser and meet other constituents from your district. I cannot overemphasize how important it is that a legislator recognize your face and name and know that you are available, if needed, to answer his questions on health issues. Your state ophthalmologic society can send you reams of information that you can communicate to legislators regarding issues of pertinence to ophthalmology.
IS MEDICAL SCHOOL A MYTH?
Optometrists? first successes ultimately began when diagnostic drugs were approved throughout the states. The huge issue of Therapeutic Practice Acts expansion transformed optometry from an optical science to an allied health profession and allowed the optometric lobby to start on a trail of diagnosis and subsequent medical (and now surgical) treatment. The Therapeutic Practice Acts, although varied in scope, have broadened optometric scope of practice nationwide, starting with topicals, moving to oral medicines, followed by narcotics and an anomalous debacle in Oklahoma with laser therapy in 1998, and culminating in incisional surgical privileging in 2004. Optometry was ostensibly based on the optical sciences; it was never intended to intrude into the practice of medicine. Yet, as time passed, optometrists? philosophy has changed. They decided that they wanted the ophthalmologist?s degree without the clinical education, medical school internship, and residency. In an editorial, a past president of the New Jersey Optometric Association referred to medical school as a myth: ?You don?t have to go to medical school to be a physician.?1 In New Jersey and other states, optometrists now advertise themselves as optometric physicians. What can we expect the public to think, when many graduates of medical schools do not know the difference between an optometrist and an ophthalmologist?
MANAGED CARE
How can ophthalmology have allowed the managed care industry to commit to the specious logic that optometrists are better gatekeepers for managed eye care because they are less expensive and know more about eye care than primary care physicians? This happened in part because ophthalmologists were busy with patients, and because most ophthalmologists and medical doctors have little or no training in business management, interpersonal relationships, or any other area needed to negotiate with a managed-care company, a lawyer, or a legislator. Optometry has reinforced the value of camping on the doorstep of decision makers. The statement, ?the absent are always in the wrong,? applied in this case.
(cont)
- Joined
- Jul 30, 2004
- Messages
- 102
- Reaction score
- 0
SCHOOLING
Admittance to medical school requires academic success. For applicants to be admitted to the top universities, they must function well in the academic setting.
Medical school teaches students how to be scientists, to think logically, and to make life-or-death decisions. These skills are not really necessary in order to interact with a politician or an insurance company. Future doctors? undergraduate classmates came to be the group that learned how to function in other areas, such as advertising, marketing, fundraising, law, politics, government, and business. That is not to say that one is better than the other but simply to explain why ?I just do not like politics? is often the mantra of the medical community. How do we explain to a scientist the logic of a legislator?s behavior? How do we train our colleagues to recognize the body language that demonstrates the politicians? inner thoughts and sometimes predicts their ultimate behavior? How do we emphasize the whole issue to fellow ophthalmologists? How do we convince a politician that an argument is logical or even morally correct? How do we convince ophthalmologists that learning these valuable lessons will allow scientists to reap tremendous professional benefits?
The politicians want to know that you are there when they need you. Either you are there with a wheelbarrow full of votes or full of money. The legislator is less concerned about votes and money if a relationship has been forged between you.
POLITICAL FUNDING
Why are ophthalmology?s PAC contributions relatively underfunded? The New Jersey experience provides an explanation. The New Jersey Optometric Association used to have a very sophisticated Web site (now it is only accessible by members) with extensive information readily available, such as ophthalmology malpractice settlements or the listing of all contributors to the New Jersey Academy of Ophthalmology PAC. Now, PAC contributions are a matter of public record, but it is surprising that New Jersey optometrists find it valuable to post this information for their members. The message is quite simple: here is a list of ophthalmologists who are contributing against us, thus supporting legislation that injures optometry, its scope of practice, and its income. Because this message is not written anywhere, its meaning becomes a matter of speculation or paranoia, but what other informative purpose could this material supply?
TAKE-HOME MESSAGE
So, who wants to chance losing optometric referrals? Play it safe. Do not contribute, or run the risk. Would you ever call an optometrist to ask why he is supporting his organization?s efforts? Why do you consider it acceptable to receive what we in New Jersey have come to refer to as ?the phone call??
Here is my point. Oklahoma no longer appears to be an aberration; numerous states throughout the country have had surgical-scope bills, laser-scope bills, narcotics bills, and oral-scope bills. Optometry?s threat of creating a ?parallel profession? therefore needs to be taken very seriously. The take-home lesson is, the absent are in the wrong. If you are not involved in the political system, it is assumed that you do not care. Get involved with your state and national academies, or optometry will define ophthalmology.
Ralph Lanciano, Jr, DO, is Clinical Associate Professor at Scheie Institute, University of Pennsylvania, School of Medicine, Department of Ophthalmology, in Philadelphia. He is the past President of the New Jersey Academy of Ophthalmology. He may be reached at (856) 665-5533; [email protected].
1. Steiner LM. Quality, cost-effective care more important than protecting turf. The Times. February 25, 1997:A13.
Admittance to medical school requires academic success. For applicants to be admitted to the top universities, they must function well in the academic setting.
Medical school teaches students how to be scientists, to think logically, and to make life-or-death decisions. These skills are not really necessary in order to interact with a politician or an insurance company. Future doctors? undergraduate classmates came to be the group that learned how to function in other areas, such as advertising, marketing, fundraising, law, politics, government, and business. That is not to say that one is better than the other but simply to explain why ?I just do not like politics? is often the mantra of the medical community. How do we explain to a scientist the logic of a legislator?s behavior? How do we train our colleagues to recognize the body language that demonstrates the politicians? inner thoughts and sometimes predicts their ultimate behavior? How do we emphasize the whole issue to fellow ophthalmologists? How do we convince a politician that an argument is logical or even morally correct? How do we convince ophthalmologists that learning these valuable lessons will allow scientists to reap tremendous professional benefits?
The politicians want to know that you are there when they need you. Either you are there with a wheelbarrow full of votes or full of money. The legislator is less concerned about votes and money if a relationship has been forged between you.
POLITICAL FUNDING
Why are ophthalmology?s PAC contributions relatively underfunded? The New Jersey experience provides an explanation. The New Jersey Optometric Association used to have a very sophisticated Web site (now it is only accessible by members) with extensive information readily available, such as ophthalmology malpractice settlements or the listing of all contributors to the New Jersey Academy of Ophthalmology PAC. Now, PAC contributions are a matter of public record, but it is surprising that New Jersey optometrists find it valuable to post this information for their members. The message is quite simple: here is a list of ophthalmologists who are contributing against us, thus supporting legislation that injures optometry, its scope of practice, and its income. Because this message is not written anywhere, its meaning becomes a matter of speculation or paranoia, but what other informative purpose could this material supply?
TAKE-HOME MESSAGE
So, who wants to chance losing optometric referrals? Play it safe. Do not contribute, or run the risk. Would you ever call an optometrist to ask why he is supporting his organization?s efforts? Why do you consider it acceptable to receive what we in New Jersey have come to refer to as ?the phone call??
Here is my point. Oklahoma no longer appears to be an aberration; numerous states throughout the country have had surgical-scope bills, laser-scope bills, narcotics bills, and oral-scope bills. Optometry?s threat of creating a ?parallel profession? therefore needs to be taken very seriously. The take-home lesson is, the absent are in the wrong. If you are not involved in the political system, it is assumed that you do not care. Get involved with your state and national academies, or optometry will define ophthalmology.
Ralph Lanciano, Jr, DO, is Clinical Associate Professor at Scheie Institute, University of Pennsylvania, School of Medicine, Department of Ophthalmology, in Philadelphia. He is the past President of the New Jersey Academy of Ophthalmology. He may be reached at (856) 665-5533; [email protected].
1. Steiner LM. Quality, cost-effective care more important than protecting turf. The Times. February 25, 1997:A13.
