Turf battles with optometry?

[cal75]

I'm an M1 interested in ophtho but was just wondering if there were any further concerns of optometrists trying to push for an expanded scope/operating. I saw a couple posts from a while ago that bills were stopped and that the AAO has been able to successfully lobby so far, but seeing the current state of events with NPs/PAs has me a bit hesitant. I think that optometrists have a better argument for an expanded scope compared to the aforementioned midlevels so personally I think it's just a matter of time, but was wondering if anyone else has more thoughts regarding this topic (especially considering that I don't know too much about the field). Thanks

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[MstaKing10]

These posts always lead to bitter battles amongst the two groups. Usually spirals into useless insults. So this is likely not the best place to post this question. Yes there are "turf battles" in Ophtalmology as there are in many other fields. I don't think there's a better argument for OD's than NP's, PA's or interventional cardiologists vs cardiothoracic surgeons or Ortho vs neurosurgeon for spine surgery etc etc etc. They all want and feel they deserve and have earned their piece of the pie. I wouldn't let this be the reason you choose not to go into ophthalmology. Regardless of what field you go into there will be some degree of this going on.

 

[RetinaDude]

In the communities where I see pts, we have a really good group of ODs. Not sure how well they get along with the local cataract docs but they get along with us retina folks really well. The huge majority are very happy doing what they do, and have no desire to do surgery.

it’s funny. Every time we heard about ODs getting a new piece of equipment (OCT), people would say ”aren’t you worried about that cutting into your business???” Quite the opposite happened. The ODs would find more pathology, and we ended up with even more referrals of true pathology.

 

[LightBox]

Fox in the hen house...

 

[90sportsfan]

I may be naive, but I never think Optometrists will end up being able to do surgery (full scope, across the board). I considered optometry at one time and think it is a cool profession. First, many of them self-select into Optometry vs Med School-Ophthalmology specifically because they don't want to do surgery. They aren't comfortable with it and when they see the potential liability, they'll be even less comfortable with it knowing they don't have years of medicine and surgical training. Second, states will question why Optometry schools exist if they do the exact same thing as Ophthamalogists, and why they should be able to practice they same scope when they have 4-6 years less medical and surgical training. For this big reason I don't see expansion of scope ever being allowed full scale. A final reason, and this isn't meant to be harsh, but nowadays the vast majority of optometrists work in the mall, Walmart, or a sun hut or optical store in a strip mall. I personally would never go to any of those locations to get any kind of surgery done. People who are willing to pay for eye surgery are usually going to at least want it in a more medical/professional setting.

 

[90sportsfan]

I respectfully disagree. Optometry schools will continue to exists just as nurse practitioners are growing in number, not having their schools close. In some cases, NPs are calling themselves "doctor" and practice independently, no different from a physician.

I also believe that before we die (within 50-60 years), optometrists will be performing breast implants, tummy tucks, and other cosmetic surgeries. They will be doing cataract surgery, a lot of it. First it will be cataract surgery, then blepharoplasties, then breast implants, then tummy tucks, then face lifts, and only then trabs and corneal transplants. It's possible that the first optometrist to do penile lengthening will occur before the first optometrist to do an exenteration.

Haha...I agree with your first part, that Optometry schools will continue to exist. I just honestly don't see them doing surgery during our careers (well at least the next 20-30 years) because there would be no point in having 2 separate training programs between Optometry and Ophthalmology/Medicine, where the latter (Optho/Medicine) provides far greater preparation for full scope eye care. Ophtos have the basic primary care training that Optometrists get, plus the general medical training which is the backbone of all healthcare. So Ophthalmology provides far more overall training.

So if anything, I see Optometry potentially folding completely or being more established midlevel providers with midlevel roles. If they are midlevel providers, I don't see them being able to do surgery. If they are ever allowed to do surgery, I see them potentially folding into medical school, somewhat like Podiatrists, although in that case, what happens to the profession of Ophthalmology. There would be no need for it to exist. Basically if both Optometry and Ophthalmology can do surgery, there is no need for 2 professions. But since surgery requires medical training, I don't see optometry being able to do it without a significant change in their training, at which point, it seems like most (decision makers) will see that it doesn't make sense since there is already the medical school route available through Ophthalmology.

 

[airplanes]

I also believe that before we die (within 50-60 years), optometrists will be performing breast implants, tummy tucks, and other cosmetic surgeries. They will be doing cataract surgery, a lot of it. First it will be cataract surgery, then blepharoplasties, then breast implants, then tummy tucks, then face lifts, and only then trabs and corneal transplants. It's possible that the first optometrist to do penile lengthening will occur before the first optometrist to do an exenteration.

Some people also believe the Earth is flat.

 

[Bronze Medal]

I also believe that before we die (within 50-60 years), optometrists will be performing breast implants, tummy tucks, and other cosmetic surgeries.

This is a bizarre opinion.

 

[hello lady!]

I may be naive....

....Second, states will question why Optometry schools exist if they do the exact same thing as Ophthamalogists, and why they should be able to practice they same scope when they have 4-6 years less medical and surgical training. For this big reason I don't see expansion of scope ever being allowed full scale.

This is naïve. Scope expansion laws (whether that be for NP, PA, CRNA, OD, etc) have nothing to do with knowledge, intelligence, training, ability, patient safety, patient access to quality care, etc. The only thing it has to do with is MONEY. If it is profitable to increase providers' billing capacity (and this money ultimately gets siphoned back to the politicians) it will continue to happen.

A final reason, and this isn't meant to be harsh, but nowadays the vast majority of optometrists work in the mall, Walmart, or a sun hut or optical store in a strip mall. I personally would never go to any of those locations to get any kind of surgery done. People who are willing to pay for eye surgery are usually going to at least want it in a more medical/professional setting.

This is factually incorrect. Most ODs work in a private practice of some sort. Only 24% work in retail as their primary location.

 

[90sportsfan]

This is naïve. Scope expansion laws (whether that be for NP, PA, CRNA, OD, etc) have nothing to do with knowledge, intelligence, training, ability, patient safety, patient access to quality care, etc. The only thing it has to do with is MONEY. If it is profitable to increase providers' billing capacity (and this money ultimately gets siphoned back to the politicians) it will continue to happen.



This is factually incorrect. Most ODs work in a private practice of some sort. Only 24% work in retail as their primary location.

It may be naïve, but none of those other providers you have listed can do surgery. SURGERY is a different ballgame and that is what we are talking about with ODs vs MD/Opths. That is the whole basis for this discussion. Optometrists have played a primary care role somewhat similar to PAs, NPs, etc for decades (well before those professions were around). Again, if they can do surgery, what is the point of Ophthalmology existing?

I don't know where you are getting your facts about working location of Optometrists. I looked into Optometry as a career and almost went to Optometry school at some point. Your first statement about ODs working in private practice is factually correct, but what you didn't mention is that many "private practices" are located in Lens Crafters, Pearl Vision, Sears Optical, Sun Hut, Opticals, etc. nowadays. Few optometrists are "employed" by retail companies, which may be the basis of your statements, but I can tell you with certainty that approx. 75% of Optometrists are not working in private practices that are in medical offices or hospitals. And I find it hard to believe that there are more than 20% working in Ophthalmology offices. Most of the "private practices" are located in retail settings. Prior to the 1990's this was not the case, but it is now.

 

[percyeye]

I have never heard any Optometrist talk about doing surgery or been at a meeting where there was a talk about Optometrists doing surgery.

If you match at Bascom Palmer I'd still go. You will have a fine career.

 

[MstaKing10]

I have never heard any Optometrist talk about doing surgery or been at a meeting where there was a talk about Optometrists doing surgery.

If you match at Bascom Palmer I'd still go. You will have a fine career.

There are scope expansion bills in multiple states requesting privileges for laser and lid procedures etc. These discussions are definitely happening

 

[percyeye]

There are scope expansion bills in multiple states requesting privileges for laser and lid procedures etc. These discussions are definitely happening

I thought we were talking cataract surgery here.

Some states have had lid procedures and lasers for years. Ophthalmologists in those states are still doing great.

The point of this wasn't to start another flame war. It was if you're interested in Ophthalmology definitely go for it. And then move to the Midwest please we need your help (talking to you Retina and Glaucoma).

 

[MstaKing10]

I thought we were talking cataract surgery here.

Some states have had lid procedures and lasers for years. Ophthalmologists in those states are still doing great.

The point of this wasn't to start another flame war. It was if you're interested in Ophthalmology definitely go for it. And then move to the Midwest please we need your help (talking to you Retina and Glaucoma).

I think this is part of the problem. I talk to optometrist who say they don't want to do surgery but would love to do lasers, lids, injections etc. That IS surgery! Laser now leads to an opening for cataract surgery or whaterver 10 years from now (as others have alluded).

Ultimately I agree with you though, if the eye is your passion by all means pursue it.

 

[dantt]

I have never heard any Optometrist talk about doing surgery or been at a meeting where there was a talk about Optometrists doing surgery.

If you match at Bascom Palmer I'd still go. You will have a fine career.

There is an optometrist in our region who gave a talk about superficial keratectomies 65400 to other optometrists implying it was easy money everybody was missing out on.

 

[percyeye]

There is an optometrist in our region who gave a talk about superficial keratectomies 65400 to other optometrists implying it was easy money everybody was missing out on.

We can all list ODs and Ophthalmologists doing shady stuff. I'm not sure I see the need for an OD to be doing a bunch of superficial keratectomies every day and how that would be a big money maker.

But again just because there is an alleged OD telling other ODs to do some sort of procedure doesn't mean a med student shouldn't pursue Ophthalmology. I bet the folks there doing cataract surgery are doing just fine.

 

[LightBox]

Let's just admit it: Optometry (as a field) want to be the gatekeepers/"PCPs" of the eye and control where the revenue flows. They are being squeezed by big box stores and Warby Parker for their optical sales, so they are trying to survive by grazing on a different pasture. Anyone who thinks differently is either an idealistic Ophtho trainee or just naive.

 

[percyeye]

Let's just admit it: Optometry (as a field) want to be the gatekeepers/"PCPs" of the eye and control where the revenue flows. They are being squeezed by big box stores and Warby Parker for their optical sales, so they are trying to survive by grazing on a different pasture. Anyone who thinks differently is either an idealistic Ophtho trainee or just naive.

ODs have grazed in that pasture for many years now. More and more Ophthalmology residents are opting for fellowships so there will be an even bigger need for general eye care coming up. If most Ophthalmologists had to do borderline glaucoma suspect checks, mild ARMD exams, diabetics with no retinopathy all day every day you'd probably jump out of a window. I know a ton that don't even want to see their own post-ops anymore because that is time they could be doing more surgery.

It is weird that Ophthalmologists are some of the highest compensated physicians in the US with the best lifestyle but there is always the doom and gloom hanging overhead.

 

[RetinaDude]

ODs have grazed in that pasture for many years now. More and more Ophthalmology residents are opting for fellowships so there will be an even bigger need for general eye care coming up. If most Ophthalmologists had to do borderline glaucoma suspect checks, mild ARMD exams, diabetics with no retinopathy all day every day you'd probably jump out of a window. I know a ton that don't even want to see their own post-ops anymore because that is time they could be doing more surgery.

It is weird that Ophthalmologists are some of the highest compensated physicians in the US with the best lifestyle but there is always the doom and gloom hanging overhead.

There’s a physician group on FB that was discussing the difficulty they were having getting in to see an ophthalmologist. These were fellow physicians who were being told, by the office front desk of course, that the MD only saw surgical patients and the patients had to see the OD for ocular medical issues. Now a lot of that has to do with the increased cataract “burden” in some communities where there are not enough MDs to handle the surgical volume. But, some of it is also what you stated and that is most of us ophthalmologists would be bored handling routine eye care

 

[MstaKing10]

That kinda stuff only happens on Facebook

 

[dantt]

There’s a physician group on FB that was discussing the difficulty they were having getting in to see an ophthalmologist. These were fellow physicians who were being told, by the office front desk of course, that the MD only saw surgical patients and the patients had to see the OD for ocular medical issues. Now a lot of that has to do with the increased cataract “burden” in some communities where there are not enough MDs to handle the surgical volume. But, some of it is also what you stated and that is most of us ophthalmologists would be bored handling routine eye care

This really depends on the market. Many of us fortunately practice in markets where we're too busy to see a new patient with pink eye same day without a referral. If another eye doctor has already seen them, I'd be happy to see them if it's determined that they need my expertise (patient saying they want to see an MD and not an OD doesn't count).

 

[percyeye]

There’s a physician group on FB that was discussing the difficulty they were having getting in to see an ophthalmologist. These were fellow physicians who were being told, by the office front desk of course, that the MD only saw surgical patients and the patients had to see the OD for ocular medical issues. Now a lot of that has to do with the increased cataract “burden” in some communities where there are not enough MDs to handle the surgical volume. But, some of it is also what you stated and that is most of us ophthalmologists would be bored handling routine eye care

I'm in an area where there is a shortage of Retina and Glaucoma docs. If I'm sending a patient for a 2nd opinion and they don't need surgery or an injection I get a tone in their note back where you can sense "why the hell did you send me this patient if they don't need surgery." I know the docs really well in the area I know how packed they are and try not to burden them with patients unless needed.

 

[ArteryStudyPainting]

Novel idea: why don't we just have enough opthalmologists?

Instead of the 200 celebrities that match every year?

 

[RetinaDude]

This really depends on the market. Many of us fortunately practice in markets where we're too busy to see a new patient with pink eye same day without a referral. If another eye doctor has already seen them, I'd be happy to see them if it's determined that they need my expertise (patient saying they want to see an MD and not an OD doesn't count).

Oh I totally agree with this sentiment. Same here. I‘m retina. For the most part, if a referring doc wants a pt seen same day, I’ll say “send em on over”. Other days, if I’m totally slammed already, I will tell referring docs to send another less busy day (unless it’s a true emergency like endo, for example). Also a big reason we don’t allow pts to self refer

 

[RetinaDude]

I'm in an area where there is a shortage of Retina and Glaucoma docs. If I'm sending a patient for a 2nd opinion and they don't need surgery or an injection I get a tone in their note back where you can sense "why the hell did you send me this patient if they don't need surgery." I know the docs really well in the area I know how packed they are and try not to burden them with patients unless needed.

Most of our referring docs are real good about this too. A lot of times the pt will want to stay with me “the specialist”, for an issue that definitely does not need my expertise. In those situations, I’ll tell them “you are already under the care of a very good doc so you don’t need both of us sending you a bill for the same problem”

 

[dantt]

Oh I totally agree with this sentiment. Same here. I‘m retina. For the most part, if a referring doc wants a pt seen same day, I’ll say “send em on over”. Other days, if I’m totally slammed already, I will tell referring docs to send another less busy day (unless it’s a true emergency like endo, for example). Also a big reason we don’t allow pts to self refer

Patients are welcome to see me "next available" without a referral for general eye care but absolutely no new urgent patients.

 

[Dusn]

I honestly think we can easily cut the patient load in half if we wanted to. A lot of the patients that get sent back to the OD don’t even need to be seeing an OD. For example if a patient is happy with their vision and has had a stable ERM for a year do they really need to be seen every year.. by anyone? They can just come back if they notice a change in their vision. Do patients with non-surgical cataracts need to be seen every single year? Any residents out there want to do a study showing that diabetics with no retinopathy and an a1c of 6 can be safely seen every other year? And the worst is how everyone gets labeled as a glaucoma suspect...

Meanwhile everyone keeps getting busier and busier and then complain that their reimbursements are getting cut because healthcare costs are a zero sum game.

Covid was enlightening. I saw a lot of my colleagues patient loads get cut drastically for several months with no adverse events. We don’t need more ophthalmologists or optoms, we just need to get better at figuring out which patients really need our continued help and which ones should stop coming back.

 

[dantt]

I honestly think we can easily cut the patient load in half if we wanted to. A lot of the patients that get sent back to the OD don’t even need to be seeing an OD. For example if a patient is happy with their vision and has had a stable ERM for a year do they really need to be seen every year.. by anyone? They can just come back if they notice a change in their vision. Do patients with non-surgical cataracts need to be seen every single year? Any residents out there want to do a study showing that diabetics with no retinopathy and an a1c of 6 can be safely seen every other year? And the worst is how everyone gets labeled as a glaucoma suspect...

Meanwhile everyone keeps getting busier and busier and then complain that their reimbursements are getting cut because healthcare costs are a zero sum game.

Covid was enlightening. I saw a lot of my colleagues patient loads get cut drastically for several months with no adverse events. We don’t need more ophthalmologists or optoms, we just need to get better at figuring out which patients really need our continued help and which ones should stop coming back.

An argument for capitation?

 

[MstaKing10]

I honestly think we can easily cut the patient load in half if we wanted to. A lot of the patients that get sent back to the OD don’t even need to be seeing an OD. For example if a patient is happy with their vision and has had a stable ERM for a year do they really need to be seen every year.. by anyone? They can just come back if they notice a change in their vision. Do patients with non-surgical cataracts need to be seen every single year? Any residents out there want to do a study showing that diabetics with no retinopathy and an a1c of 6 can be safely seen every other year? And the worst is how everyone gets labeled as a glaucoma suspect...

Meanwhile everyone keeps getting busier and busier and then complain that their reimbursements are getting cut because healthcare costs are a zero sum game.

Covid was enlightening. I saw a lot of my colleagues patient loads get cut drastically for several months with no adverse events. We don’t need more ophthalmologists or optoms, we just need to get better at figuring out which patients really need our continued help and which ones should stop coming back.

Couldn't disagree with you more. These routine follow ups oftentimes reveal other ocular issues. And I don't trust any patient to come back only if they are symptomatic. They are notorious for waiting too long or not coming in at all despite worsening. Especially diabetics.

I'm busy but always happy to evaluate and send back to referring doc with PRN follow up only if truly not urgent.

I suppose HMO or single payer type healthcare system this will be the norm. In 10-20 years we will all be following this plan maybe

 

[RetinaDude]

There needs to be a happy balance of continued monitoring vs safely sending the pt back to the OD. I’ve got a fair number of pts I could easily put down as prn. An example is a lady I lasered ten years ago for lattice with a tear. Actually, I’ve lasered all the lattice areas in both eyes. She’s also got a Weiss ring OU. With the PVD, and stability for ten years, I’ve advised her she really doesn’t need to see me anymore. Despite my best efforts, she almost breaks down crying about how scared she is for me to not monitor her eyes. It’s truly a waste of her time, and mine, for her to come to my office, endure a two hour wait, and then be told “looks the same as last year”. I’m just not tough enough to put my foot down and say “nope, you gotta go so I can make room for others”

 

[MstaKing10]

Until she detaches at the border of prior laser or develops a new atrophic hole with sub retinal fluid. I think retina is different. And I'll admit I'm quite conservative, but rarely do I PRN patients with prior laser to tears or prior RD. Post pucker or macular hole or whatever is no biggie and I'll discharge to their primary eye doc pretty quickly. Diabetics I have treated before I also keep. I will make exceptions when I know patient is compliant and has a great OD or general ophtho that I know and trust. Otherwise, I will see them. It's a short visit and keeps patient happy. Win win as far as I'm concerned.

 

[LightBox]

Retina draining the healthcare dollars lol. Haha, you know I had to say it!

 

[TheLesPaul]

breast implants and liposuction

one is not like the other

 

[DrZeke]

Until she detaches at the border of prior laser or develops a new atrophic hole with sub retinal fluid. I think retina is different. And I'll admit I'm quite conservative, but rarely do I PRN patients with prior laser to tears or prior RD. Post pucker or macular hole or whatever is no biggie and I'll discharge to their primary eye doc pretty quickly. Diabetics I have treated before I also keep. I will make exceptions when I know patient is compliant and has a great OD or general ophtho that I know and trust. Otherwise, I will see them. It's a short visit and keeps patient happy. Win win as far as I'm concerned.

I agree about the laser patients. I won't let go of them. Nobody will scleral depress them. They will do optos in a lot of cases undilated or dilated and miss most of the pathology that needs to be seen on dynamic scleral depression.