Scope of practice opinions...

[posner]

I just wanted to see if my sentiments are echoed by the masses. I liken optometry in the eyecare business to family medicine in the medical game. WHile I acknowledge I am not and should not perform surgery, I do believe there are many procedures that we should all be performing.

I routinely remove chalazions and papillomas etc, dilate and irrigate puncta, insert and remove plugs, treat glaucoma, perform scleral depression, gonio, treat every red eye I see, work patients up for systemic disease when idicated, order imaging when needed, and I am sure to be involved with the PCP and the medical management of my patients.

As a resident I have removed a few pterygiums under the watchful eye of the attending Ophthalmologist, and while It is not particularly difficult, I do not think it necessarily fits into the scope of optometric practice. Stromal punctures I have done and it certainly is not rocket science. I also think that ODs should be able to perform SLT and YAGs. I dont think LASIK should be performed by ODs. I do not think there should be restrictions on oral meds we prescribe, and I think injectibles would be nice for the removal of superficial lesions and chalazions. Am I missing anything? I really think this would be fair to all involved and would also lead to better patient care in the end. Leave the legitiamte surgeries to the surgeons. I am assuming proof of reasonable proficiency would need to be demonstrated by ODs for some of these procedures. What do the masses think?

Posner

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[PBEA]

I just wanted to see if my sentiments are echoed by the masses. I liken optometry in the eyecare business to family medicine in the medical game. WHile I acknowledge I am not and should not perform surgery, I do believe there are many procedures that we should all be performing.

I routinely remove chalazions and papillomas etc, dilate and irrigate puncta, insert and remove plugs, treat glaucoma, perform scleral depression, gonio, treat every red eye I see, work patients up for systemic disease when idicated, order imaging when needed, and I am sure to be involved with the PCP and the medical management of my patients.

As a resident I have removed a few pterygiums under the watchful eye of the attending Ophthalmologist, and while It is not particularly difficult, I do not think it necessarily fits into the scope of optometric practice. Stromal punctures I have done and it certainly is not rocket science. I also think that ODs should be able to perform SLT and YAGs. I dont think LASIK should be performed by ODs. I do not think there should be restrictions on oral meds we prescribe, and I think injectibles would be nice for the removal of superficial lesions and chalazions. Am I missing anything? I really think this would be fair to all involved and would also lead to better patient care in the end. Leave the legitiamte surgeries to the surgeons. I am assuming proof of reasonable proficiency would need to be demonstrated by ODs for some of these procedures. What do the masses think?

Posner

I think you'll get plenty of support in the OD forum. Try posting this in the OMD forum and you'll soon see where the obstacles are.

 

[posner]

I think you'll get plenty of support in the OD forum. Try posting this in the OMD forum and you'll soon see where the obstacles are.

You might be surprised at what many ODs think. Forward thinkers would tend to agree with me, but there are plenty of others that dont necessarily embrace expanding scopes. I believe that common sense will prevail in the end. Just think that 25 years ago ODs were not allowed to put diagnostic drops of any kind into the eyes of patients; we have come a long way. WHile organized medicine is a powerful lobby, optometry has proven also to be well organized. The scope has not only been expanding around the US, but there have been recent expansions overseas as well. Stay tuned.

POsner

 

[rpie]

You might be surprised at what many ODs think. Forward thinkers would tend to agree with me, but there are plenty of others that dont necessarily embrace expanding scopes. I believe that common sense will prevail in the end. Just think that 25 years ago ODs were not allowed to put diagnostic drops of any kind into the eyes of patients; we have come a long way. WHile organized medicine is a powerful lobby, optometry has proven also to be well organized. The scope has not only been expanding around the US, but there have been recent expansions overseas as well. Stay tuned.

POsner

I totally agree with you Posner! Obtaining the ability to do the procedures and privileges you mentioned, will fully define what Optometry has grown into.

 

[drgregory]

see my arguement about "od's are overtrained". everything you mentioned that an OD should be doing is routinely taught in most OD schools. i also agree that ODs are not prepared for lasik, and certainly not anywhere near prepared to perform any open globe surgery.
hey - maybe if we didnt work in shopping malls we'd be more apt to get approval on these things.

 

[posner]

see my arguement about "od's are overtrained". everything you mentioned that an OD should be doing is routinely taught in most OD schools. i also agree that ODs are not prepared for lasik, and certainly not anywhere near prepared to perform any open globe surgery.
hey - maybe if we didnt work in shopping malls we'd be more apt to get approval on these things.

Greg...you are baiting me. You know my strong opinions on the commercial OD. Knock it off. I could hardly sleep last night after I got all fored up on another topic. I am trying to behave.

Posner

 

[drgregory]

Greg...you are baiting me. You know my strong opinions on the commercial OD. Knock it off. I could hardly sleep last night after I got all fored up on another topic. I am trying to behave.

Posner

i cant help it.

 

[posner]

see my arguement about "od's are overtrained". everything you mentioned that an OD should be doing is routinely taught in most OD schools. i also agree that ODs are not prepared for lasik, and certainly not anywhere near prepared to perform any open globe surgery.
hey - maybe if we didnt work in shopping malls we'd be more apt to get approval on these things.

Now be fair, afterall the doc in the boxes set their own fees, call their own shots, and make every attempt to ensure patients understand the value of their services. Otherwise, how could you possibly explain the intense loyalty their patients have for them? Furthermore, dont try to tell me that you havent thought to yourself, "if I ever need medical eyecare, I'll run down to Wally world so I can pick up some vacuum bags when I am done."

Posner

 

[Ryan_eyeball]

Now be fair, afterall the doc in the boxes set their own fees, call their own shots, and make every attempt to ensure patients understand the value of their services. Otherwise, how could you possibly explain the intense loyalty their patients have for them? Furthermore, dont try to tell me that you havent thought to yourself, "if I ever need medical eyecare, I'll run down to Wally world so I can pick up some vacuum bags when I am done."

Posner

Here ya go until we get things changed

http://www.aamc.org/students/amcas/start.htm

 

[blazenmadison]

and I think injectibles would be nice for the removal of superficial lesions and chalazions. Am I missing anything? I really think this would be fair to all involved and would also lead to better patient care in the end. Leave the legitiamte surgeries to the surgeons. I am assuming proof of reasonable proficiency would need to be demonstrated by ODs for some of these procedures. What do the masses think?

Posner

injections will be on the new NBEO starting 2008. so we're moving in that direction.

 

[JR]

...I think injectibles would be nice for the removal of superficial lesions and chalazions.

Just curious, how would you know if that "superficial lesion" is not malignant melanoma, BCC, SCC, actinic keratosis, keratoacanthoma, neurofibroma, capillary or cavernous hemangioma or necrobiotic xanthogranuloma associated with malignant melanoma? Do you guys get training in ocular oncology?

 

[UABopt]

Just curious, how would you know if that "superficial lesion" is not malignant melanoma, BCC, SCC, actinic keratosis, keratoacanthoma, neurofibroma, capillary or cavernous hemangioma or necrobiotic xanthogranuloma associated with malignant melanoma? Do you guys get training in ocular oncology?

After general pathology and systemic pathology as well as several hours devoted to dermatology in our anterior segment courses I feel quite confident that I can identify a lesion as being “suspicious.” You can make a very educated estimation of what the lesion is but nobody knows for sure. In fact just the other week I had a patient in our clinic at school who had a suspicious lesion on her superior lid margin, it turned out to be SCC. The point is any tissue removed is sent to pathology regardless, they are there to make the definitive evaluation at a histological level.

 

[posner]

In my office, we also send tissue samples to the lab for histological analysis/confirmation. Just for your info JR, this is exactly the same process that our Oculoplastics guy goes through when he removes lesions. While I dont claim to be a dermatologist or an oncologist, I have had a fair amount of training in lid and anterior segment lesions both as a student and a resident. Again, my intention was to reinforce the idea that I think we should be able to excise certain lesions, not necessarily every lump and bump we see.

On a side not, my family physician took a lump off my dads neck about 2 years ago with a #11 blade and called it a skin tag. Of course it came back less than a year later and was removed again by a dermatologist. However, not only was it actually basal cell carcinoma, it was actually quite large and required a pretty extensive excision. Is it OK because our family physician has the letters MD behind his name to make this kind of mistake? Didnt he have pretty extensive training in this area? My point is, I think if you look at the data, OD's as a whole tend to be very cautious and comprehensive(because we have the likes of you breathing down our neck waiting to hang us when we make the slightest error). This is not to say we dont make errors, but I will say I have seen many buthchers in our area that hide behind the letters at the end of their name.

Lastly, as I previously mentioned, I dont want to be a surgeon nor do I think most ODs want to be surgeons. If I wanted to be a surgeon, I would have stayed in Med school after I completed my first year. We do however, want to take care of our patients without having to be babysat by the OMD community. I think this issue is mucn more about ego than it is about what is best for patient care.

POsner

 

[16846]

On a side not, my family physician took a lump off my dads neck about 2 years ago with a #11 blade and called it a skin tag. Of course it came back less than a year later and was removed again by a dermatologist. However, not only was it actually basal cell carcinoma, it was actually quite large and required a pretty extensive excision. Is it OK because our family physician has the letters MD behind his name to make this kind of mistake?

Actually, your mistake was going to the FP in the first place for a skin lesion. The derm. should have been your first stop, not your second. FP's are good for colds/coughs not strange lesions.

Also, if I need anything more than an updated script or a contact lens fitting, I go to my OMD since I know if it does turn out to be anything serious he can provide the continuity of care I will need.

 

[VA Hopeful Dr]

Actually, your mistake was going to the FP in the first place for a skin lesion. The derm. should have been your first stop, not your second. FP's are good for colds/coughs not strange lesions.

Also, if I need anything more than an updated script or a contact lens fitting, I go to my OMD since I know if it does turn out to be anything serious he can provide the continuity of care I will need.

I dunno, I think the mistake was the FP not sending the excised tissue off to pathology. I worked with an FP that removed several lipomas from a guy. He was pretty sure their were benign, but he still sent each one off to be looked at.

To each his own on the OD/MD debate. Do what makes you feel taken care of. I don't think anyone can argue against that.

 

[16846]

I dunno, I think the mistake was the FP not sending the excised tissue off to pathology. I worked with an FP that removed several lipomas from a guy. He was pretty sure their were benign, but he still sent each one off to be looked at.

To each his own on the OD/MD debate. Do what makes you feel taken care of. I don't think anyone can argue against that.

Excellent points

 

[PBEA]

Actually, your mistake was going to the FP in the first place for a skin lesion. The derm. should have been your first stop, not your second. FP's are good for colds/coughs not strange lesions.

Also, if I need anything more than an updated script or a contact lens fitting, I go to my OMD since I know if it does turn out to be anything serious he can provide the continuity of care I will need.

Good point, although in today's insurance environment, where FP, PA, and CRN's can often serve as gatekeepers, the referral may not be given (or asked for). How is the unsuspecting pt to know any better? Posner's example also highlights what I consider to be a HUGE double standard in medicine. OD's get slammed for providing sound, competent eyecare based on definitive objective examination, ALL of which is standard clinical practice. Yet when an the FP, PA, CRN, launches some antibiosis on the "pink eye" they just "examined", and it turns out to be iritis that leads to synechia that leads to glaucoma, then this is OK?!!? Why because they have an MD? Gimme a break, I dont think so. Oh and that pt, who finally had to come on their own to my office (3 weeks later), for whom WE had to obtain the referral from the MD, after appropriate, directed treatment (by me an OD ) with atropine, steroid, and beta blocker resolved quite nicely. Needless to say I d/c'd the pointless f**king antibiotic.

 

[posner]

Good point, although in today's insurance environment, where FP, PA, and CRN's can often serve as gatekeepers, the referral may not be given (or asked for). How is the unsuspecting pt to know any better? Posner's example also highlights what I consider to be a HUGE double standard in medicine. OD's get slammed for providing sound, competent eyecare based on definitive objective examination, ALL of which is standard clinical practice. Yet when an the FP, PA, CRN, launches some antibiosis on the "pink eye" they just "examined", and it turns out to be iritis that leads to synechia that leads to glaucoma, then this is OK?!!? Why because they have an MD? Gimme a break, I dont think so. Oh and that pt, who finally had to come on their own to my office (3 weeks later), for whom WE had to obtain the referral from the MD, after appropriate, directed treatment (by me an OD ) with atropine, steroid, and beta blocker resolved quite nicely. Needless to say I d/c'd the pointless f**king antibiotic.

I see this type of thing a couple times a week. It is laughable. Most MDs are nothing but pill pushers who rather than think about what is actually going on, just have the patient pop a pill. We dont even need to get into the numbers regarding how many patients are killed each year by MDs not fully understanding drug/drug interactions. I am shocked at how ego driven the OMD community is even to the point of putting down FPs as good for only "coughs and colds". It all seems pretty ridiculous to me.

Posner

 

[Ben Chudner]

And here we go again....

 

[rpie]

I see this type of thing a couple times a week. It is laughable. Most MDs are nothing but pill pushers who rather than think about what is actually going on, just have the patient pop a pill. We dont even need to get into the numbers regarding how many patients are killed each year by MDs not fully understanding drug/drug interactions. I am shocked at how ego driven the OMD community is even to the point of putting down FPs as good for only "coughs and colds". It all seems pretty ridiculous to me.

Posner

This is one of many reasons why my youngest brother left FP for Optometry. In many cases insurance company did not look kindly on him when he referred a “simple red eye”. The reason he did not desire to treat the “red eyes” is because he understood the possibility of itritis, uveitis etc. One year he was asked to reconsider his referral patterns since they felt he was referring too many “eye problems that are with in the scope of FP”.

 

[KHE]

And here we go again....

Sad, but true.

This thread should be closed immediately because we can already see where it's heading and it's not going to accomplish anything at all.

All ODs and OMDs have seen patients for problems that a family practice doctor treated with sulfacetamide. Big deal.

All ODs have seen patients for 2nd opinions regarding cataract surgery that were 20/20 OU.

All OMDs have seen ODs refer things that are boneheaded beyone belief.

Pointing to the "mistakes" that other profession(al)s make is the absolute worst kind of "gotcha" because every single solitary one of us is guilty of doing or not doing things that we look back on in retrospect and wonder what the hell we were thinking.

I've treated patients for conditions that did not resolve and then they went somwhere else and another doctor fixed them and they think I"m an idiot.

I've treated patients for conditions where I've been the 4th doctor they've seen and the first three docs didn't help them, but I fix the problem and the patient thinks I walk on water. However, more often than not, I would have initially tried the treatements that the first three doctors tried. In those cases, I have the advantage of knowing what has already been tried and NOT worked.

I strongly urge the moderator to close this thread.

 

[Olddog1]

I see this type of thing a couple times a week. It is laughable. Most MDs are nothing but pill pushers who rather than think about what is actually going on, just have the patient pop a pill. We dont even need to get into the numbers regarding how many patients are killed each year by MDs not fully understanding drug/drug interactions. I am shocked at how ego driven the OMD community is even to the point of putting down FPs as good for only "coughs and colds". It all seems pretty ridiculous to me.

Posner

You generalize more than any other person on the planet (note the irony of that generalization). One post on the website and that means every MD agrees that FPs are only for colds and coughs. The statement "most MDs are nothing but pill pushers" again shows your lack of comprehension on what it is we do all day. Just because a skin tag was removed that was a BCCa and now all docs are idiots? Last week a local optom dilated somebody into angle closure. Should I now conclude by your logic (and apparently PBEA's as well) that all ODs have no idea how to use (in this case didn't use) a gonio lens so we should take away those little red bottles? It doesn't matter what initials you have behind your name, it matters how you well you can examine the patient, assimilate the information and come up with a plan.

Lastly: "because we have the likes of you breathing down our neck waiting to hang us when we make the slightest error", the likes of you should be the lawyers and patients, not us. When patients come into my office who have been mismanaged, either by OD (yes that happens as well) or MDs, the response is the same: I wasn't there, we can only go forward from here (you would be a ***** to say anything else because then the trial lawyer comes in and makes you part of the case).

 

[Ben Chudner]

Actually, your mistake was going to the FP in the first place for a skin lesion. The derm. should have been your first stop, not your second. FP's are good for colds/coughs not strange lesions.

Also, if I need anything more than an updated script or a contact lens fitting, I go to my OMD since I know if it does turn out to be anything serious he can provide the continuity of care I will need.

I agree that you should go where you feel most comfortable with your care. I would also point out, however, that if you see a general ophthalmologist and there is something wrong such as a suspicious lid lesion, or retinal detachment you will be referred to a specialist. Exactly the same way you would if you saw an OD. I am not trying to convince you to see an optometrist, but I just like to point out that in most areas where access to care is not an issue, OD's practice very similar to general ophthalmologists with the obvious exception of cataract surgery and therefore you have a false sense of continuity of care.

 

[posner]

You generalize more than any other person on the planet (note the irony of that generalization). One post on the website and that means every MD agrees that FPs are only for colds and coughs. The statement "most MDs are nothing but pill pushers" again shows your lack of comprehension on what it is we do all day. Just because a skin tag was removed that was a BCCa and now all docs are idiots? Last week a local optom dilated somebody into angle closure. Should I now conclude by your logic (and apparently PBEA's as well) that all ODs have no idea how to use (in this case didn't use) a gonio lens so we should take away those little red bottles? It doesn't matter what initials you have behind your name, it matters how you well you can examine the patient, assimilate the information and come up with a plan.

Lastly: "because we have the likes of you breathing down our neck waiting to hang us when we make the slightest error", the likes of you should be the lawyers and patients, not us. When patients come into my office who have been mismanaged, either by OD (yes that happens as well) or MDs, the response is the same: I wasn't there, we can only go forward from here (you would be a ***** to say anything else because then the trial lawyer comes in and makes you part of the case).

You make several good points. I would lke to point out that this thread was originally intended for discussing proposed scope of practice issues until it was hijacked; I did not intend to pit OD vs MD. My only point is that within reason I want to be able to take care of my patients from beginning to end. I dont want to have to waste the patients time and money for something that is well within my capabilities. I dont want to perform surgery. I have no problem referring a patient that needs specialized care, in fact I do it routinely.

Just out of curiosity, do you throw a gonio lens on every patient before you dilate? If you do, you are the exception. I see 25-35 patients a day(80% of whom I dilate) and while I do grossly assess angles prior to dilating, I dont use a gonio lens unless specifically indicated. IN closing, I would like to echo your sentiment; it does not matter which initials follow your name, what is most important is the examination of the patient, the interpretation of the data, and the plan. For the record, I would like to apologize for my generalizations made earlier.

POsner

 

[drgregory]

You generalize more than any other person on the planet (note the irony of that generalization). One post on the website and that means every MD agrees that FPs are only for colds and coughs. The statement "most MDs are nothing but pill pushers" again shows your lack of comprehension on what it is we do all day. Just because a skin tag was removed that was a BCCa and now all docs are idiots? Last week a local optom dilated somebody into angle closure. Should I now conclude by your logic (and apparently PBEA's as well) that all ODs have no idea how to use (in this case didn't use) a gonio lens so we should take away those little red bottles? It doesn't matter what initials you have behind your name, it matters how you well you can examine the patient, assimilate the information and come up with a plan.

Lastly: "because we have the likes of you breathing down our neck waiting to hang us when we make the slightest error", the likes of you should be the lawyers and patients, not us. When patients come into my office who have been mismanaged, either by OD (yes that happens as well) or MDs, the response is the same: I wasn't there, we can only go forward from here (you would be a ***** to say anything else because then the trial lawyer comes in and makes you part of the case).

i for one am amazed by the ability of FPs. i have several local MD family pract groups. we get along well. what was interesting to me was their ability to have knowledge in areas of eyecare i assumed they didnt. i wasnt so sure they would know what a cover test was. they did. really, if you think about the cognitive ability expected of a family MD or internist, its quite amazing. this isnt to downplay any surgical profession, as seeing patients in consultation while a definative diagnosis is expected ASAP isnt a walk in the park either. i agree with KHE - shut this thread down. EVERY ONE OF US, even lowly ODs like me with an oversize ego, can admit to mistakes made.

 

[Olddog1]

You make several good points. I would lke to point out that this thread was originally intended for discussing proposed scope of practice issues until it was hijacked; I did not intend to pit OD vs MD. My only point is that within reason I want to be able to take care of my patients from beginning to end. I dont want to have to waste the patients time and money for something that is well within my capabilities. I dont want to perform surgery. I have no problem referring a patient that needs specialized care, in fact I do it routinely.

Just out of curiosity, do you throw a gonio lens on every patient before you dilate? If you do, you are the exception. I see 25-35 patients a day(80% of whom I dilate) and while I do grossly assess angles prior to dilating, I dont use a gonio lens unless specifically indicated. IN closing, I would like to echo your sentiment; it does not matter which initials follow your name, what is most important is the examination of the patient, the interpretation of the data, and the plan. For the record, I would like to apologize for my generalizations made earlier.

POsner

Completely unrelated to the scope of practice issue, I actually do gonio everybody before I dilate them the first time (referral glaucoma practice) and if there is something concerning on prior gonios (narrow, etc..). It only takes 30 seconds for a quick peek with a Sussman lens after checking IOP. Should be careful with von Herrick, sometimes this will fool you, esp in hyperopes. For the record, I have done PI's on many patients who were lucky not to have occluded by OMD dilation.

 

[16846]

Good point, although in today's insurance environment, where FP, PA, and CRN's can often serve as gatekeepers, the referral may not be given (or asked for). How is the unsuspecting pt to know any better? Posner's example also highlights what I consider to be a HUGE double standard in medicine. OD's get slammed for providing sound, competent eyecare based on definitive objective examination, ALL of which is standard clinical practice. Yet when an the FP, PA, CRN, launches some antibiosis on the "pink eye" they just "examined", and it turns out to be iritis that leads to synechia that leads to glaucoma, then this is OK?!!? Why because they have an MD? Gimme a break, I dont think so. Oh and that pt, who finally had to come on their own to my office (3 weeks later), for whom WE had to obtain the referral from the MD, after appropriate, directed treatment (by me an OD ) with atropine, steroid, and beta blocker resolved quite nicely. Needless to say I d/c'd the pointless f**king antibiotic.

That's why I hate the gatekeeper setup, most of the time all it seems to do is delay the proper treatment for most people. If my insurance company bitches that I need a referral and I don't think it can wait I just pay for it out of pocket, I'm not about to let some pencil pusher jeopardize my health, ocular or otherwise.

If I had the choice between an FP, PA, CRN, and an OD to take care of my eyes, it would be an OD any day of the week.

 

[posner]

Completely unrelated to the scope of practice issue, I actually do gonio everybody before I dilate them the first time (referral glaucoma practice) and if there is something concerning on prior gonios (narrow, etc..). It only takes 30 seconds for a quick peek with a Sussman lens after checking IOP. Should be careful with von Herrick, sometimes this will fool you, esp in hyperopes. For the record, I have done PI's on many patients who were lucky not to have occluded by OMD dilation.

This is great clinical insight. I have switched exclusively to the Sussman because of the ease of use compared to the goldmann. YOu are right in that it only takes a few seconds. There really is no excuse for not doing it, but I, like most others in primary care settings(non referral centers), have grown complacent and have not been burned by a closure yet. Of course every glaucoma suspect gets a gonio and every other patient for that matter where it is specifically indicated. See how nice it is when we can discuss things in a non confrontational manner? Thanks for your reply.

POsner

 

[PBEA]

I think there is a difference between a mistake made by an OD or OMD vs PCP, FP, PA, CRN. The difference is we (OD/OMD) use specific objective findings to determine a diagnosis. The rest are basing their diagnosis on history, and limited findings. This is not the same thing as a real eye exam. I'm not saying I've never made a mistake, or have never missed something, but my example was not meant to show that I am infallible. It was meant to show the DOUBLE STANDARD that exists in eyecare. Non-ophthalmic MD's simply do not receive sufficient training in regards to the eye, conditions that affect it, or methods of eye assessment. I think it borders on malpractice, as these conditions are beyond their scope of practice. I have donned my flame ******ant suit, so feel free to respond.

Sorry, Posner, but I'm really off-topic here.

 

[POJO]

I think there is a difference between a mistake made by an OD or OMD vs PCP, FP, PA, CRN. The difference is we (OD/OMD) use specific objective findings to determine a diagnosis. "...QUOTE]


I'm not sure that this is a reasonable statement and unlikely to be supportable by normal practice. I think that not nearly as many diagnoses as you think are based upon irrefutable physical signs and symptoms which are pathognomic for only a single entity. Rather, I would presume that many diagnoses in optometry are just as empirical as any other branch of health care.

 

[Olddog1]

I think there is a difference between a mistake made by an OD or OMD vs PCP, FP, PA, CRN. The difference is we (OD/OMD) use specific objective findings to determine a diagnosis. The rest are basing their diagnosis on history, and limited findings. This is not the same thing as a real eye exam. I'm not saying I've never made a mistake, or have never missed something, but my example was not meant to show that I am infallible. It was meant to show the DOUBLE STANDARD that exists in eyecare. Non-ophthalmic MD's simply do not receive sufficient training in regards to the eye, conditions that affect it, or methods of eye assessment. I think it borders on malpractice, as these conditions are beyond their scope of practice. I have donned my flame ******ant suit, so feel free to respond.

Sorry, Posner, but I'm really off-topic here.

I'm sorry to be off topic as well, but the answer is standard of care. The standard of care for an eye care professional is different than standard of care for a FP doc. The standard is based on how reasonable health care providers in an area treat a certain condition. Each provider is compared to someone with an equal level of training. So, there really is no double standard. An FP is compared to another FP, and you are compared to another OD. If you think about the number of red eyes that go into an FP's office (or the ER for that matter), how many are something "bad"? Likely very few. These patients usually get a little polytrim and the red eye clears (and it likely would have without polytrim). If there is pain with a red eye, most are referred. While they may miss the occasional angle closure (which may cost some optic nerve), uveitis, and the rare tumor. How much morbidity is there from a day or two delay? Probably not much. I'm not saying it's right, or I would want to be that person with red eye, but it's not like they are missing a pupil involved 3rd (hopefully).

 

[PBEA]

I'm not sure that this is a reasonable statement and unlikely to be supportable by normal practice. I think that not nearly as many diagnoses as you think are based upon irrefutable physical signs and symptoms which are pathognomic for only a single entity. Rather, I would presume that many diagnoses in optometry are just as empirical as any other branch of health care.

I disagree. If you are referring to early allergic or early viral, or some "zebra", or some "unknown", then those are the exception to the rule. The rule is that diagnosis, at least in the eyecare game, are almost totally derived from purely objective findings. Period. I can "prove" my diagnosis, by presenting my exam results. I dont use "intuition" and very little empirical data to support my diagnosis. Calling a red eye a "pink" eye is not a diagnosis.

 

[PBEA]

I'm sorry to be off topic as well, but the answer is standard of care. The standard of care for an eye care professional is different than standard of care for a FP doc. The standard is based on how reasonable health care providers in an area treat a certain condition. Each provider is compared to someone with an equal level of training. So, there really is no double standard. An FP is compared to another FP, and you are compared to another OD. If you think about the number of red eyes that go into an FP's office (or the ER for that matter), how many are something "bad"? Likely very few. These patients usually get a little polytrim and the red eye clears (and it likely would have without polytrim). If there is pain with a red eye, most are referred. While they may miss the occasional angle closure (which may cost some optic nerve), uveitis, and the rare tumor. How much morbidity is there from a day or two delay? Probably not much. I'm not saying it's right, or I would want to be that person with red eye, but it's not like they are missing a pupil involved 3rd (hopefully).

I understand what you say about the "standard of care", and this is really the core of my discontent. This "standard of care" basically allows that someone who receives VERY limited exposure to such a sensitive and complicated part of the body, has carte blanche to treat what ever in the hell they choose!!? And you justify this by saying what? That most people heal on their own anyway? Then in the same breath you admit that its wrong, and that you would not want to be that pt? Sorry, but not only is that is a double standard (as applied to OD's), but the FP standard (as applied to eyecare) is unmitigated horsesh***. The PCP's I've worked side by side with in a clinical setting, could care less about eye stuff. You either had to be in severe pain or blind (i'm exagerating here) for them to even address it. I'll also add, the fact that many eye conditions are misinterpreted by the doctor/patient or are asymptomatic anyway, so who's to say what they are missing? I dont think the data is available, or can be estimated with any accuracy. As for pupil involved 3rd, hopefully they do the workup, but is that really appropriate without an outside consult? I mean what about a pupil spared 3rd vasculopath? My guess is that they will do the same workup, right? How appropriate is that? Thats akin to rxing abx for "pink" eye IMHO.

 

[PBEA]

You might be surprised at what many ODs think. Forward thinkers would tend to agree with me, but there are plenty of others that dont necessarily embrace expanding scopes. I believe that common sense will prevail in the end. Just think that 25 years ago ODs were not allowed to put diagnostic drops of any kind into the eyes of patients; we have come a long way. WHile organized medicine is a powerful lobby, optometry has proven also to be well organized. The scope has not only been expanding around the US, but there have been recent expansions overseas as well. Stay tuned.

POsner

CRICKET? CRICKET? OK, Ill try and put this on topic.

Posner- Surprised? Yes I would be. In the past, I've worked with some low scope OD's (they tend to be older, but not all older OD's are this way). I know some cringe at the thought of treating anything medically, and for good reason! But I always assumed they supported some increased scope. I've seen the overseas developments in the periodicals, and it seems to confirm what I have been stating all along. As you say, hopefully common sense will prevail.

 

[posner]

CRICKET? CRICKET? OK, Ill try and put this on topic.

Posner- Surprised? Yes I would be. In the past, I've worked with some low scope OD's (they tend to be older, but not all older OD's are this way). I know some cringe at the thought of treating anything medically, and for good reason! But I always assumed they supported some increased scope. I've seen the overseas developments in the periodicals, and it seems to confirm what I have been stating all along. As you say, hopefully common sense will prevail.

It will prevail. It must. Let's be honest, the OMDs dont REALLY(at least not entirely) want what is best for their patients. They really want what is best for their wallets. They employ fear tactics and smear campaigns to denigrate optometry and preserve a larger piece of the pie for themselves. It is this simple. The primary eyecare patient can be handled equally well by OD or MD. WHile I have seen countless ODs that would prefer to rx spectacles and contacts only, I have also come across a few OMDs that are quick to refer even remotely challenging cases(my good friend the retina specialist informs me that he routinely gets what he feels are open and shut diagnoses from OMDs). It would be foolish to compare the training an optometrist receives to that of an OMD, but I feel it is equally foolish to try and take away from the more than adequate training ODs receive that makes us capable of managing 95% of patients.

I believe that optometry would be making a big mistake trying to heavily delve into the surgical realm of eyecare. I do believe the procedures I mentioned earlier in this thread are well within the scope of optometric practice. I think many OMDs feel that ODs will not stop pressing scope of practice until they can pull up a chair behind a VISX. I for one, dont want this to be the case. I would love to see OD/MD relationships improve accross the board. We are more of a team than most realize, if we can get past the egos and become more constructive. We are lucky in our practice and in our area. THe OMDs want to be in the OR as much as possible. They appreciate the 70-80 CE/IOL patients my office sends them each month along with the LASIK patients. They know I know when to refer a patient, and they have faith in my clinical skills(as evidenced by thier willingness to send patients immediately back to me after a confirmatory consult). The whole OD/MD debate is a waste. If we all really only cared about what was best for our patients, the world would be a better place.

Posner

 

[Ben Chudner]

Let's be honest, the OMDs dont REALLY(at least not entirely) want what is best for their patients. They really want what is best for their wallets.

Statements like this are what continue to create friction between the two professions.

 

[posner]

Statements like this are what continue to create friction between the two professions.

You are right There are less inflammatory ways to approach this situation. It is difficult to sit back and listen to OMDs denigrate ODs. I would love to have an objective meeting of the minds of both professions and hash out a scope that would make both sides happy. I do feel that OMDs run with what the radical minority of ODs might want the scope to be and fail to acknowledge that there a many very competent ODs who want nothing more than to take the best possible care of their patients without rolling them into the OR tp perform surgery.

I do believe there is a middle ground that is reasonable; how we will ever reach that middle ground is another story. There does exist a comfortable symbiosis of the two professions. The busier we keep the OMDs in the OR, the less likely they are to fight scope issues(so long as they dont include involved surgical procedures).

Posner

 

[Olddog1]

It is difficult to sit back and listen to OMDs denigrate ODs.

Posner

I know exactly how you feel. Except it is 1/posner.

 

[eyedoc1991]

I just wanted to see if my sentiments are echoed by the masses. I liken optometry in the eyecare business to family medicine in the medical game. WHile I acknowledge I am not and should not perform surgery, I do believe there are many procedures that we should all be performing.

I routinely remove chalazions and papillomas etc, dilate and irrigate puncta, insert and remove plugs, treat glaucoma, perform scleral depression, gonio, treat every red eye I see, work patients up for systemic disease when idicated, order imaging when needed, and I am sure to be involved with the PCP and the medical management of my patients.

As a resident I have removed a few pterygiums under the watchful eye of the attending Ophthalmologist, and while It is not particularly difficult, I do not think it necessarily fits into the scope of optometric practice. Stromal punctures I have done and it certainly is not rocket science. I also think that ODs should be able to perform SLT and YAGs. I dont think LASIK should be performed by ODs. I do not think there should be restrictions on oral meds we prescribe, and I think injectibles would be nice for the removal of superficial lesions and chalazions. Am I missing anything? I really think this would be fair to all involved and would also lead to better patient care in the end. Leave the legitiamte surgeries to the surgeons. I am assuming proof of reasonable proficiency would need to be demonstrated by ODs for some of these procedures. What do the masses think?

Posner

I agree that Optometry can and should be able to perform more procedures.
However, I hope we do not become too "focus" on other procedures that we forgot our primary area of expertise is still in refraction. The most common complaint from patients is still "poor vision and headache with the new glasses". Have you seen how OMD refract?

 

[Olddog1]

I agree that Optometry can and should be able to perform more procedures.
However, I hope we do not become too "focus" on other procedures that we forgot our primary area of expertise is still in refraction. The most common complaint from patients is still "poor vision and headache with the new glasses". Have you seen how OMD refract?

We actually don't refract. During residency we ALL get a random number generator as a departing gift.

 

[POJO]

I agree that Optometry can and should be able to perform more procedures.
However, I hope we do not become too "focus" on other procedures that we forgot our primary area of expertise is still in refraction. The most common complaint from patients is still "poor vision and headache with the new glasses". Have you seen how OMD refract?

Dear eyedoc1991,

I used to think that optometry's obsession or preocupation with refraction had prompted such things as graphical analysis or OEP analysis (ergo, the term vision analysis). In reality, the refractive component of an eye evaluation is just a part of the eye. Yet in its infancy, optometry created an approach to analyze the eye where even most experts would agree that such measurements are highly variable and have questional reliability.

Agreed that a good refraction is important, but a good refraction still only takes minutes. I'd hate to go to all of that schooling to be able to do a 5 minute procedure 40 times a day.

 

[acurarte]

If you want to pick up a scalpel or use a laser, go to medical school. It's really quite simple.

My father is an OD in a large private practice and is an excellent doc. I also have other family members that are OD's. When I was looking at medical school vs optometry, I decided I wanted to perform surgery. Therefore, I went to medical school. I suffered through many years of training and am finally completing ophthalmology residency at age 33. I am sorry, but if you want to invade tissue, then pay your dues and get the extra training. Our training, though sharing many parallells, differs in many regards. Our training in systemic diseases and surgery differs greatly. When an applicant is trying to get into optometry school, he/she understands that surgery will not be part of their future career.

If optometry would make a national effort to accept their current scope of practice, we could all join forces to lobby for increased reimbursements instead spending millions fighting eachother on scope of practice issues. This would make too much sense.

 

[eyedoc1991]

Dear eyedoc1991,

I used to think that optometry's obsession or preocupation with refraction had prompted such things as graphical analysis or OEP analysis (ergo, the term vision analysis). In reality, the refractive component of an eye evaluation is just a part of the eye. Yet in its infancy, optometry created an approach to analyze the eye where even most experts would agree that such measurements are highly variable and have questional reliability.

Agreed that a good refraction is important, but a good refraction still only takes minutes. I'd hate to go to all of that schooling to be able to do a 5 minute procedure 40 times a day.

If the refraction is so easy, why can't we delegate that to our techs? Why can't Optician refract? If Optometry is moving forward toward medical procedures, should we abandon what we started? I agree that the technical aspect of refraction may seem easy but the "prescribing" part is still not an easy decision to make otherwise we would not have "Rx recheck" from our patients. I like to see Optometry do more but I rather see we get pay equal amount for the same procedures that Ophthalmology do.

 

[POJO]

"....If optometry would make a national effort to accept their current scope of practice, we could all join forces to lobby for increased reimbursements instead spending millions fighting eachother on scope of practice issues. This would make too much sense.

Dear acrarte,

Will you be a supporter of AAO (Amer Acad oph) PAC against optometry? If so, then we might be interested in what you think the maximum scope of practice that would be acceptable to ophthalmology so that we can lay to rest this constant bickering.

 

[POJO]

If the refraction is so easy, why can't we delegate that to our techs? Why can't Optician refract? If Optometry is moving forward toward medical procedures, should we abandon what we started? I agree that the technical aspect of refraction may seem easy but the "prescribing" part is still not an easy decision to make otherwise we would not have "Rx recheck" from our patients. I like to see Optometry do more but I rather see we get pay equal amount for the same procedures that Ophthalmology do.

Here is where I disagree, I believe that it is acceptable to have different pay rates for the same procedure or IC9. In medicine, I believe that a physical assessment by a Nurse Practitioner is paid differently than by a physician. I would probably need some confirmaiton on this.

 

[acurarte]

Dear acrarte,

Will you be a supporter of AAO (Amer Acad oph) PAC against optometry? If so, then we might be interested in what you think the maximum scope of practice that would be acceptable to ophthalmology so that we can lay to rest this constant bickering.

Look the only way to end the bickering is by having the "moderates" from both sides meet, make a proposal and for both sides to stick to their word once an agreement is made. Would this ever be possible? I am not sure. It just makes too much darn sense and seems way too logical. Sometimes reality defies logic and common sense.

There seems to be a small percentage on both sides that act as the "Jihad" extremists. I would certainly be willing to participate in a movement aimed at both sides coming to an agreement. Do I support legislation aimed at retaining surgery and lasers for physicians trained in surgery? Yes, but we have to draw a line in the sand somewhere.

When I recommend a specialist, surgery or procedure to my patient I always ask myself, "is this what I would recommend for my mother or child?" If the answer is yes I recommend it. Being raised in an optometric family I can still say that I would not recommend having surgery by anyone that did not go through the rigors of medical school and a surgical residency. I would absolutely recommend an OD taking care of specialty contact lenses and would feel very comfortable having them look at a red eye.

Optometry is not going anywhere and there are plenty of patients for everyone. We need to learn how to play in the sand box together so we can fight the real enemies, those who want to pay us less and less for what we all do which is taking good care of patients.

 

[POJO]

"....Optometry is not going anywhere and there are plenty of patients for everyone. We need to learn how to play in the sand box together so we can fight the real enemies, those who want to pay us less and less for what we all do which is taking good care of patients.

I think that is a laudable and I for one would agree on this. By the way, see the bold. Was this a slip of the late night typing? or...?

 

[acurarte]

Late night. Sorry.

 

[PBEA]

If you want to pick up a scalpel or use a laser, go to medical school. It's really quite simple.

My father is an OD in a large private practice and is an excellent doc. I also have other family members that are OD's. When I was looking at medical school vs optometry, I decided I wanted to perform surgery. Therefore, I went to medical school. I suffered through many years of training and am finally completing ophthalmology residency at age 33. I am sorry, but if you want to invade tissue, then pay your dues and get the extra training. Our training, though sharing many parallells, differs in many regards. Our training in systemic diseases and surgery differs greatly. When an applicant is trying to get into optometry school, he/she understands that surgery will not be part of their future career.

If optometry would make a national effort to accept their current scope of practice, we could all join forces to lobby for increased reimbursements instead spending millions fighting eachother on scope of practice issues. This would make too much sense.

Dear acurarte,

I agree, you do have a unique perspective to share in this thread. I like your argument and I agree with your outcome. I graduated 6 years ago, and I can tell you with all certainty that I am unable to use a scalpel for anything, and I may have shot a few lasers but I would never consider myself able to use them on anything other then dead eyemeat. I do handle minor (even moderate) corneal or conjunctival foreign bodies (20 gauge needle), punctal plugs, and epilation pretty much round up my "surgical" aspirations. However, save some multifactorial complex exceptions, I do feel comfortable with virtually any other aspect of ophthalmology/optometry. Also, my training has made me keenly aware of my abilities and limitations, I am constantly learning. I know better then you when one of my patients needs to see an ophthalmologist, or a PCP, or even another optometrist. I'll assume your dad entered optometry some 40 years ago when OD education and scope of practice were very much different then now. I'm not claiming "superiority" but I have to wonder, does your opinion on ODs scope of practice reflect an OD training 40 or 50 years ago, or does it reflect the training that I received? If it reflects the "older" model of optometry then we will never agree. And we will never get to those fargin reimbursement concerns.

 

[PBEA]

Here is where I disagree, I believe that it is acceptable to have different pay rates for the same procedure or IC9. In medicine, I believe that a physical assessment by a Nurse Practitioner is paid differently than by a physician. I would probably need some confirmaiton on this.

I disagree with your comments. If I diagnose diabetic retinopathy, you can be damn sure that I should (and do) receive the same reimbursement as an ophthalmologist. I dont know what an NP does (I hope its not eyes), but it does not compare to what I do (which is eyes). My diagnosis will be accurate and I will be paid for it. Are you a resident, because I thought this was pretty common knowledge among "real" world practitioners.