Taste of their own medicine...

Discussion in 'Ophthalmology: Eye Physicians & Surgeons' started by Andrew_Doan, Apr 24, 2004.

  1. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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  2. Gleevec

    Gleevec Peter, those are Cheerios
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    What is especially interesting is a post by doinkOD on that thread:

    "This is exactly the type of response I am hoping to get from the public. I trust that our patients are samrt enough to make the right decision for themselve, once they are presented with the facts. The unfortunate thing is that, Opticians present false information to the public and try to misinform patients, in an attempt to legitimize their greed for more money.
    To answer your question, it is not the actual act of refraction by Opticians that is putting public in danger, but rather it is the fact that refraction is just one important part of a whole eye examination. The result of the refraction, along with the results of many other tests that are performed in a comprehensive eye examination by an Optometrist or an Ophthalmologist, gives much information about the ocular and general health of the patient. Many systemic diseases and a number of diseases of the oculo-visual system manifest themselves as a change in refraction. These diseases will be overlooked by an Optician who will simply give new glasses to the patient and the patient will see better with his/her new glasses, but the real underlying and potentially dangerous cause for the change in the refaction is not addressed...That's why it is so unfortunate that Opticians are abusing public's lack of total understanding of the issue and equating refraction with the prescription."

    For the purposes of this forum and this post you can replace the words:
    Optician with Optometrist
    Optometrist with Ophthalmologist
    Refraction with Surgery

    Incredible symmetry I must say, but I guess they know how MDs feel like.
     
  3. Yogi Bear

    Yogi Bear 2K Member
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    what's refraction?
     
  4. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    Measuring the glasses prescription of an eye, i.e. refractive error of an eye.
     
  5. MPS

    MPS Senior Member
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    I think that we all have to concede that, given the appropriate training, an optician could perform subjective refraction and an optometrist could perform surgery. The latter topic seems to be continually dredged up - if we use the case of maxillofacial surgery as an example, then we'd have to concede that you don't need a medical degree to perform surgery (at least not in the US). Having said that, optometrists would need a substantial amount of additional training to perform surgery, and I can't see how they'd acquire this training (unless ophthalmologists were willing to pass on their skills). Moreover, given the oversupply of people willing to train in ophthalmology, I don?t see the need to train optometrists to perform surgery.
     
  6. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    Good points! :thumbup:

    I cannot see how optometry will learn to perform surgery without: 1) aggressive political lobbying, and 2) ophthalmologists to train them.

    Expanding residency spots for optometry (assuming that they have the background for a medical/surgical residency) is not an option because: 1) each residency spot costs society ~$100,000 in regards to Medicare support and this money is always decreasing, and 2) there is not a need for increased number of surgeons.

    Time and time again, it is the ophthalmologists who shoot themselves in the foot in regards to the ever expanding optometric scope of practice. First, it's co-management. Second, it's greed and financial pressure that lures academic programs to build surgical suites in optometry schools. This story is a scary proposition.

    The Illinois College of Optometry (ICO) is very aggressive in the IL legislature in regards to scope of practice battles. ICO placed the Senate President's wife on their Board of Trustees. Graduates of ICO were sent to Wisconsin and led the charge for laser surgery in WI.

    The University of Chicago Ophthalmology Department is facing tough times and is surrounded by several productive Ophthalmology Departments in the Chicago area. The current chairman at Chicago is ready to retire in 2004 but establishes a cooperative educational venture with ICO. This educational venture allows ICO to send students to U of Chicago clinics, requires Chicago staff to teach at ICO, and ICO refers surgical patients to Chicago. ICO and U of Chicago planned to build a new $3.6 Million, two-suite ophthalmic surgery center near downtown Chicago (5 miles from the U of Chicago). This new surgery center is 100% owned by the college of optometry. U of Chicago ophthalmologists "will perform ALL surgeries at the new facility."

    Why was this done? It was because the current chair at Chicago couldn't "get O.R. time", Chicago CEO said ophthalmic surgery not profitable, and the benefit to ICO is clear.

    To make a long story short, the construction required a contract between Chicago and ICO; however, the current Chicago Chair is retiring in May 2004. The new Chair (Dr. William Mieler, MD) refuses to continue this "educational endeavor" with ICO.

    If the above situation occurs, then this is how optometry will slowly gain surgical rights without the proper training (and no, watching a few surgeries as an optometry student is NOT enough to be a surgeon). Ophthalmology has it's own training programs and optometry has theirs. There is no need to combine the two fields.
     
  7. doc05

    doc05 2K Member
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    what's so hard about refraction?? "read line 1...which is better: 1 or 2...2 or 3..."
     
  8. exmike

    exmike NOR * CAL
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    This is quite interesting. They're OD's want to aggressively expand into surgical procedures yet they claim they are vigorously defending their right to refract claiming that opticians aren't "trained" to do so, and thus could negatively impact a patients helath. I think they need to come up with a consistent agenda and stick to it.
     
  9. TomOD

    TomOD Senior Member
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    For the record, I'm 100% in favor of allowing associate-degreed Opticians a license to refract. For Optometry, many will go kicking and screaming. But this will be the best way to get lazy Optometrists out of Walmart, Costco and the like..........overnight.
     
  10. exmike

    exmike NOR * CAL
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    well since you're encroaching on the "turf" of ophthalmologists with your focus on advanced procedures, refracting probably doesnt interest you anyway.
     
  11. MPS

    MPS Senior Member
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    Andrew,

    I don't see the University of Chicago venture as being inherently evil - one could argue that exposing optometry students to ophthalmology clinics is in the public's interest. The move within certain sectors of optometry to gain surgical privileges is not in the public's interest; it is driven by certain optometrist's ambition to strive for some sort of professional fulfilment.

    As an aside, I find it rather ironic that those on the ophthalmology side of the fence are championing their status as surgeons. It wasn't so long ago that surgeons were considered to be a rung below physicians. It just goes to show how far good publicity gets you...........................................
     
  12. MPS

    MPS Senior Member
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    What's wrong with optometrists working at Walmart etc.? The prevalence of refractive blindness & visual impairment in Baltimore is as high as that in some third world countries - I'd argue that Walmart, Costco "and the like" go some way towards making eyecare & spectacles relatively accessible to those on low incomes.
     
  13. TomOD

    TomOD Senior Member
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    Actually, I refract every day. But I also do many other things. I like the variety. From diagnosing a kid with convergence insufficieny, to a routine exam, to a glaucoma patient, to a next-day post-operative cataract follow-up, to an ortho-K case, to a corneal foreign body, to rxing Restasis for a chronic dry eye patient, to fitting contacts, to counseling diabetic patients on retinopathy, to training a pt on how to do lid scrubs, etc....

    I am willing to allow trained Opticains to perform refractions because (1) I am not a hypocrite and (2) With their excellent knowledge of optics, I think they will do a great job. Will they miss pathology? Probably. But just as with ODs, if there are a great number of problems, the public will find out and it will be ended. We don't live in a vacuum.

    I'm not afraid of others acquring knowledge and "stealing my job". I think it would be a wonderful idea if everyone on the planet could learn and understand about their eye health and refractive status. People with knowledge don't scare me. This is one of the reasons I agreed to teach physician assistant students AND their supervising MDs how to use the slit lamp and how to do a better job with assessment and treatments as they relate to the eye. Will they be able to remove a minor piece of trash from the peripheral cornea and take money away from me? I hope so. I'm not afraid of other professions because I know I'm good at mine. I'm always learning and this forum in one of my learning experiences. :thumbup:
     
  14. Gleevec

    Gleevec Peter, those are Cheerios
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    Uhh, sometimes the only optometrists in a poor part of the country that the poor can afford are at Walmart, Costco, etc. I fail to see how optometrists satisfying that need is "lazy." In fact, these optometrists should probably be commended.

    Its incredible, I cant agree with a SINGLE thing you say regardless of the topic. We must be polar opposites.
     
  15. TomOD

    TomOD Senior Member
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    Maybe we should talk about abortion :D :D

    My comment about ODs working at Walmart and the like is not that they provide poor care. Its strictly about imagine. Until we see MDs, DDs, DPMs working next to the frozen food section, it will provide amble ammunition to those that would like to keep ODs doing nothing but refracting -2.00 myopes.

    Optometry has an image problem and the ODs working there are not helping it. Thats all. ODs are not working there as a public service to humanity. They are working there because the corporation pays 99% of the overhead and the OD can walk in and out with good money. Unfortunately, he must answer to the optical head which more times than not is not even a trained optican but an assistant manager promoted from the pet department.

    The U.S. has an overly healthy welfare system that provides care to anyone that needs it. No one is going without eye care that wants it. There are private offices that are just an inexpensive as Walmart.
     
  16. doinkOD

    doinkOD Junior Member

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    I really don't get why Optometrists are fighting so hard to do surgeries. As I have said before, here in Canada it is actually more difficult to get into the only Optometry school in the whole country with 60 spots available, than into over 900 medical school spots in Ontario alone. I had applied to both and Medicine was my back up plan which I decline their offer after I was admitted into Optometry school. So, I made the decision at that time that I was interested in practicing Optometry and not Ophthalmology, which means I was not interested in doing surgeries. This, I can confidently say, is the position of all my colleagues whol graduated with me, and I can say all, because we only have one English speaking school in Canada. I never chose Optometry to be a pseudo-Ophthalmologist, but rather I wanted to be an excellent Optometrist. So, this talk of doing srugery really does not make much sense to me. There is a whole different path to follow if one is interested in doing surgeries and it is called Medical school. May be things are different in the US because there are so many more spots in Optomery school, which are mostly private schools. Also, health care is covered in Canada and money is not as much of an issue as possible. So, here those Optometrists who do work in Walmart, Cosco, etc. are really the lazy ones, since eye care is covered in Ontario for all regardless of where you practice. Anyway, I am probably going to be yelled at my many in this forum, since the direction of the profession seems to be different down in the US from here in Canada, but I like how it is in Canada and I think it is working really well. We have great working relationship with the Ophthalmologists and we work great together as a team to provide best eye care to our patients. As a results, we all make very good leavings too :D
     
  17. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    I agree with the above. However, I don't agree with having an optometry school owning a surgical center and having their students observe surgery with ophthalmology attendings. This is a political and strategic move to allow optometrists in Illinois to claim that they are qualified to perform surgery. :rolleyes:

    The latter will not serve the public's interest.

    This is from OSN 4/15/2004
    ________________________

    Controversy has revolved around the development of a surgery center at the Illinois College of Optometry. According to the college, the center was proposed by the University of Chicago.

    Arol Augsburger, OD, president of the Illinois College of Optometry, said the concept is based on the relationship the two schools have had. For 6 years, he said, the two schools have been affiliated and have provided training in a joint environment. The idea was that a surgery center at the college of optometry would be more cost-effective than one at the University of Chicago?s hospital, he said.

    ?At the college, we have property adjacent to our existing facilities. This is an issue that was brought to our attention by the University of Chicago, and from a business perspective it made good sense,? said Leonard Mesner, OD, vice president for patient care services at the college.

    Dr. Augsburger said having a surgery center at the optometry school would allow students to understand aspects of surgery that will be valuable if they are to provide primary eye care to patients.

    ?We think it?s vitally important that two disciplines like this, that have related missions, work together in the training and patient care programs. It?s important that the optometrist understand the surgery ? while recognizing the role the ophthalmologist plays. ? That can only be done by setting up a model like this arrangement,? Dr. Augsburger said.

    Rich Paul, executive director of the Illinois Association of Ophthalmology, questioned the need for the optometric surgery center.

    ?Why would they need [the center] except that they?re introducing their students to surgery?? he asked.

    Allen Putterman, MD, an oculoplastic surgeon in Chicago, Ill., said many ophthalmologists in the state are concerned the center could lead to surgical training of optometrists. In the past, he said, optometrists have used aspects of their training, such as classes in pharmacology, to obtain privileges from state legislatures. He said that although may be is valuable for optometrists to know about surgery, optometrists? attempts to obtain surgical rights in various states are an overriding concern to ophthalmologists.

    ?Obviously, [optometrists] wouldn?t be involved initially in surgery. There is just a concern that it could happen, and that they could use that as a method for getting privileges,? Dr. Putterman said.

    He said plans for the center are on hold until a new chairman assumes head of the department of ophthalmology at the University of Chicago.

    Outgoing department of ophthalmology chairman J. Terry Ernest, MD, PhD, declined to comment for this article, as did his successor, William Mieler, MD.
     
  18. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    Thank you for your comments in the forum. :thumbup:
     
  19. Richard_Hom

    Richard_Hom Senior Member
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    Dear Forum,

    It's rather sad, as I see, that there isn't more collegiality between optometry and ophthalmology. However, this wrangling may have been avoided quite early if optometry had not developed outside the mainstream medical system.

    As most physicians know, the medical system has many "checks and balances" which would have developed scopes of practices, procedural borders, etc for optometrists had they been involved earlier in the medical system.

    In this regard, the University of Chicago/Illinois College of Optometry should be seen as a blessing whereby ophthalmology might be able to exert influence on the outcome of surgcial privileges for optometry. As everyone knows, should the outcome be left to legislation, the outcome might either be unsatisfactory for one or the other. I think the two programs are really economically driven rather than "political". If optometry is to be "frozen" out of medical plans, then it is quite likely that owning the faciltiy becomes more important than actually doing the procedure. If you look it in this fashion, then one sees the ambulatory surgical centers, imaging equipment, lasers as an attempt by physicians and their investors to capture their fair share of the facilities reimbursement. So, I think this battle about surgical privileges in some circumstances is on point but in some other circumstances, it is oversimplified, in my opinion.

    Lastly, medicine has already been successful in "muzzling" public optometry school graduates, who in general are less aggressive about this subject than our private school brethren. I guess that lesson has been lost. You see, working together from the beginning could actually save us all a whole lot of heartache and money after all. Or not!

    Regards,
    Richard_Hom
     
  20. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    As always, thank you for your comments. It's nice to see different perspectives on this important issue. :)

    Fighting in the courts is never a good thing. It's expensive and ultimately destroys the relationship between two great organizations. Unfortunately, in the state of Oklahoma, organized optometry has not ceased to stop their aggressive lobbying and push for surgical independence. The dodging of established surgical privileging mechanisms through legislation is wrong. If organized optometry continues to push, then the AAO and ophthalmologists cannot sit and watch as the standard of care for patients erode.
     
  21. smiegal

    smiegal Member
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    "It's rather sad, as I see, that there isn't more collegiality between optometry and ophthalmology. However, this wrangling may have been avoided quite early if optometry had not developed outside the mainstream medical system." Dr. Hom

    The legal fight for surgical privileges by optometrists in Oklahoma is the single greatest threat to collegiality between ophthalmology and optometry. Your philosophical waxings on the evolution of eye care, with all due respect, are irrelevant at this point. Until organized optometry openly discourages these types of actions, ophthalmologists-in-training (like myself) have no option but to view your field and its aspirations with great skepticism. Until then, optometry as a whole will inevitably be viewed as the potential threat that it is to patient's vision. A short-cut in training is indefensible as there is an adequate supply of well-trained ophthalmic surgeons.
     
  22. DrC

    DrC New Member

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    There isn't enough room here to adequately cover this topic, but I have always felt that there is more room for agreement between ODs and OMDs than either side would like to admit.
    Both sides tend to point to their best and brightest as examples of their "rank and file" when that it not true, while shining the spotlight on the worst practitioners and most vivid horror stories about the "other guys". The truth is that all disciplines have good and bad. That's not the real point, though.

    If ophthalmology would concede that optometry has achieved primary eye care provider status... meaning that we are optical, visual and medical care providers and stop all the state legislative aggression, then we might have more room to talk. I would bet that OMDs would be willing to talk about that if ODs would agree to quit going after surgery privileges. Maybe not. Even at that, what is the definition of surgery? There could be a question about whether or not ODs can do procedures except for the fact that it has already been done. We aren't talking "what if". ODs have been doing injections, small procedures and lasers for years and nobody is coming up with damaged patients or dead bodies as a result. To my knowledge, there is not a single case of malpractice, court settlement or patient harm reported in Oklahoma or in the VA system. That even surprises me. No profession can have a 100% success record, but I believe the OK stats are valid since there is so much intense scrutiny going on. ODs in NC and WV have had therapeutic privileges for 30 years and none of the OMD horror show predictions have materialized. There just isn't any credibility in the OMD argument that ODs can't ______. It's been done.

    Should ODs do surgery? Certainly, the vast majority should not - at least not now. But it depends on the definition of surgery. Lesion injections, lumps and bumps, skin tags, chalazia, epilation, lacrimal plugs, FB removal, lacrimal 2 snip, etc. That shouldn't be a big deal. SLT is a no brainer. Electron microscopy of SLT treated eyes are indistinguishable from non-treated eyes. Where's the "surgery" there? PIs, YAG capsulotomy? No brainers. Even if those procedures were universally available to ODs right now, the majority would not do them.
    On the other hand, CE/IOL, oculoplastics, setons, trabs, strabismus, intraocular kenalog, etc. - nah. ODs should not do that. If we aspire to do those things then we will risk diluting the patient population and probably end up lowering the overall level of surgical care. I believe we need to have surgeons doing more surgery to keep their skills up, not less. That said, I have practice with OMDs, I know exactly what OMD practice and training amounts to... and there is no question in my mind that the majority of OMDs are overtrained for the job from a general medicine perspective. I've been there, I know.

    CAN ODs do surgery? Sure. I just don't believe that society would be well served by having ODs do surgery, but they could. We have enough eye surgeons as it is. Many of them are practicing meatball primary care to get by. If there were fewer OMDs and they were all very busy doing procedures, do you think we would be fighting about the primary care stuff? Of course not. There would be no economic reason for OMDs to be threatened and they would be glad to punt the lower level stuff that would clog up their schedules. That's not the current reality, however.

    So, what do we do? I think that ophthalmology would be well served to attempt to bury the hatchet by accepting that optometry has evolved to the point that primary medical eye care is a reality. In other words, give up the fight since we just about have that war won anyway. On the flip side, I think optometrists should concentrate on maintaining their traditional training in optical and visual patient care and we should continue to improve our training and expertise in medical eye care so that all the states would be more uniform in terms of scope of practice. The two big issures are: 1. optometry doesn't want to be arbitrarily cut out of future technology. 2. what is the definition of surgery?
    What if one day someone builds a "box" that fixes certain eye problems and doesn't entail "surgery" per se? Who can use it? ODs? OMDs? SLT is a good example. It doesn't cut or burn or alter anatomy... and it is easy to do.
    We just don't want to be left out for no good reason. That's why we have to be careful to protect our status.

    I am certain that this could be worked out and then ODs and OMDs could save a ton of time and money and live happy and productive lives. Life is short. It is sure easier to say it than accomplish it. Too bad.
     
  23. doinkOD

    doinkOD Junior Member

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    What an excellent posting DrC. You have managed to express, very eloquently, the thoughts and feelings of over 95% of Optometrists all over North America. Thanks. :thumbup: :)
     
  24. exmike

    exmike NOR * CAL
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    My question to all the OD's that want to do "simple surgical procedures" is this. If you wanted to do those, why didnt you just go to medical school and become an OMD? Then you wouldnt have had to fight for those rights, and you would be justs as well trained for all the "primary care" procedures as well. Doesnt it make more sense to be trained and competent in a wide scope of practice (OMD) and choose to do what you want (may just focus on simple procedures) rather than to gain a relatively narrow scope of training and competency (OD) and attempt to expand your scope of practice beyond that after the fact?
     
  25. GeddyLee

    GeddyLee Bad-ass Guitarist
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    Well I don't see why opticians can't do refractions. Seems perfectly reasonable to me.

    As for the OD's doing surgery bit...who is going to train these guys? I mean, I'm assuming only OMD's are presently doing eye surgery, so why would OMD's train OD surgeons? As for the OD's in OK doing laser surgeries...where did they get trained to do that?
     
  26. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    By ophthalmologists. :(

    You should read my previous post about U of Chicago Ophthalmology and Illinois College of Optometry building a surgical center together. It's not going to happen now, but it only requires a few greedy physicians to destroy our profession. Co-management and greed also contribute to the training of optometrists. There are practices where surgeons are performing 50 cataract surgeries per day and then transferring the patients to ODs for the post-operative care. The ODs then rationalize that if they care for patients pre-operatively and post-operatively, then why not learn how to do the surgery? Co-management can be good if done correctly, but often, I think patient care truly suffers because of greedy eye care providers.
     
  27. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    DrC, nice post. I agree with most of what you wrote; however, lasers are surgical instruments. SLT may seem "easy", but in the wrong hands will result in 360 degrees PAS and angle closure. It's not so trivial when this happens.

    Malpractice suits are not a good measure of how well optometry is performing in OK or in general. None of the data you mentioned have been published and most of them are exaggerated claims like 12,000 laser procedures without any problems. Statistically, this is impossible. No procedures are without complications.
     
  28. medduck

    medduck Member
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    Trained by ophthalmologists? I hope that the University of Oklahoma was not involved in that- I assume it was private practice OMDs looking to make an extra buck.

    It seems that one motivating factor for ODs to expand their scope of practice is to recoup some of the monetary losses from decreased reimbursement after the explosion of managed care. Maybe organized optometry should consider producing fewer ODs to combat this situation- to bring the supply vs. demand curve back into their favor. I noticed 1400 ODs graduate every year and this number has not changed for awhile. Newly trained OMDs, on the other hand, number about 430 per year, down about 15% from the mid 90's. With fewer ODs, maybe exam/overall reimbursement would increase, because they would have more negotiating power- like the dentists?

    Dentists decreased their grads from 6000 per in 1980 to just over 4000 today. It seemed to work for them.

    Maybe decreasing the # of ODs is not a good idea because there are so many patients needing care. It justs seems from reading some of these posts that there are ODs and OMDs on every street corner fighting over patients.
     
  29. smiegal

    smiegal Member
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    "On the other hand, CE/IOL, oculoplastics, setons, trabs, strabismus, intraocular kenalog, etc. - nah. ODs should not do that. If we aspire to do those things then we will risk diluting the patient population and probably end up lowering the overall level of surgical care." Dr. C

    "What an excellent posting DrC. You have managed to express, very eloquently, the thoughts and feelings of over 95% of Optometrists all over North America." DoinkOD


    So you both agree that the most recent events in OK legislation (expanded scope to non-laser surgical privileges "as authorized by the Oklahoma Board of Examiners in Optometry") would be potentially detrimental to patient care . Optometrists who share your viewpoint should communicate with one another and make a consensus statement to that point. Surely, you would not want your profession to tacitly approve something that you believe to be harmful to patients.
     

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