Why the ophthalmologist and optometrist conflict should concern patients

If you need laser eye surgery in the state of Kentucky, or a little cosmetic work around the eyelids, it now behooves you to ask your prospective surgeon the following question before signing the operative consent form:

“Say doc, did you go to medical school?”

Kentucky joined the company of Oklahoma earlier this year as the second state to conflate optometrists and ophthalmologists. Only ophthalmologists are the sort of doctors who graduated from medical school, did an internship, completed a three-year residency in eye surgery, possibly a fellowship after that, and have achieved and maintained national board certification through a program of lifelong learning in their specialty.

Optometry schools (four-year programs focused on optics to prescribe glasses and contacts and the diagnosis and management of certain eye-related diseases) have a tough application process too, and many of the same students going into optometry could have chosen medicine. But nobody ever really faces a clear-cut choice of going into optometry or ophthalmology. Even if you do exceedingly well in medical school, you could easily miss out on an ophthalmology residency slot. Ophthalmology is among the most selective specializations in medicine. Yet despite having earned a reputation within medical science as one of its most advanced and storied fields, these days ophthalmology is challenged with its branding, of all things. Perhaps it’s the funny spelling?

Nationwide, about 30 percent of consumers don’t know the difference between the two types of eye doctors, according to a survey conducted by the National Consumer’s League (the NCL designed the study independently, then applied for and received unrestricted funding from the American Academy of Ophthalmology, which did not commission the study). Ninety-five percent of the 600 Americans surveyed wanted an M.D. wielding the scalpel or the laser if they needed eye surgery. Regular everyday people seem to sense that the eyes are part of the body, that serious disease might have something to do with the whole, and that at the very least, you might want a full-service clinician involved if something becomes complicated enough for an invasive procedure.

Proponents of optometry’s expansion argued that having optometrists perform in-office laser eye procedures, inject medications into eyes, and cut out “lumps and bumps” around the eyes increases health care access for Kentucky’s rural citizens (Kentucky’s Medicaid program can spend $150 in transportation credits for a $50 ophthalmology check-up). Optometrists outnumber ophthalmologists by a ration of four to one and can be found in most Kentucky counties.

But while you could easily be forgiven for imagining that Kentucky’s leadership must now be hot on the trail of other ways to foster health care accessibility, like chiropractic spine surgery or cosmetic surgery parlors, do not expect the complete democratization of medicine until back adjusters and cosmetologists can pay to play with the same skill as optometrists. Mistaking optometry for ophthalmology was no Mr. Magoo moment.

“If you go back and look at our involvement in politics in terms of contributions, we’ve always been involved,” says Dr. Ian Benjamin Gaddie, president-elect of the Kentucky Optometric Association. “We work hand-in-hand in the community with these people and that makes a huge difference.”

Efforts included lobbying state legislators while they were immobilized in the optometric examining chair, reports indicate.

“In many states it’s just how the stars line up, and how your luck goes as you run the gamut through the political process,” Dr. Gaddie told me.

The Louisville Courier-Journal’s Frankfort bureau chief Tom Loftus followed the blue grass stardust:

“Kentucky optometrists and their political action committee have given campaign money to 137 of the 138 members of the state legislature and Gov. Steve Beshear, contributing more than $400,000 as they push for a bill to expand their practices.

Members of the Kentucky Optometric Association and its PAC have given at least $327,650 to legislative candidates in the last two years alone and have hired 18 lobbyists to help them make their case.

They also gave a total of at least $74,000 more to Beshear’s re-election campaign, the Republican gubernatorial campaign of Senate President David Williams and the House and Senate political caucuses.”

Optometry waged state-by-state expansion of practice battles for four decades on its way to where the profession stands now, which is increasingly nebulous. The American Academy of Ophthalmology and the American Medical Association have challenged optometry every step as optometry blurs its boundaries with medicine. A patchwork quilt of legislation around the country variably delineates optometric practice. Now two patches have little pockets for scalpels and lasers.

For optometrists, serving us as the “primary health care professional for the eye” means what the state says it does, and that can vary widely, creating confusion among patients and the rest of the medical world. Citing how in some states optometrists must obtain certifications for medications they have no intention of ever using, the American Society of Health-System Pharmacists pointed to optometrist licensure as an example to avoid.

Optometrists have been dilating eyes since the 1970s to better diagnose eye diseases, and have been using local medications in most states since the 1980s. They no longer face opposition from ophthalmology on these fronts. “We draw the philosophical line in the sand with surgery,” says Dr. David Parke, chief executive officer of the American Academy of Ophthalmology.

Ophthalmologists have successfully fought back in 25 other state battles where optometrists asked legislatures to let them perform surgery, he says, by pointing out the difference in quality of training and management of adverse events.

While chair of the University of Oklahoma’s Department of Ophthalmology for 17 years, Dr. Parke dealt with the aftermath of upgraded optometric licensure in that state. He says the problems he saw were the result of “not knowing what you don’t know.”

Dr. Parke’s experience included treating a man whose “skin tag” was excised by an optometrist. Nine months later the patient came to the university medical center with an invasive, substantive squamous cell carcinoma that required a massive reconstructive surgery. “We asked the patient, ‘Why’d you let him do that?’ He replied, ‘Well he’s a doctor, he had on a white coat and he said he could.’”

In another case, an elderly patient with severe end-stage glaucoma could only be controlled surgically through a technique called filtering blebs. “She went to an optometrist who said to the patient, ‘Mrs. Jones, you have cysts on your eyes, I should take care of those now,’ and he proceeded to excise them, completely undoing the surgery.”

“In the end it scares me, quite frankly,” says Dr. Parke.

The most common laser procedure Kentucky optometrists will perform involves using a YAG laser to clear a membrane that becomes cloudy in some patients after lens replacement surgery (it’s something ophthalmologists do as needed on post-cataract surgery follow-up appointments). The procedure may take only 20 minutes to learn and looks as simple as a video game. But complications can occur.

“You can be a pilot, and say, ‘I’m just going to fly in good weather’ — but you never know when it’s gonna get dark, or when the storm’s gonna come up,” says Dr. Woodford Van Meter, president of the Kentucky Academy of Eye Physicians and Surgeons. ”You can go get an amateur pilot’s license, but that doesn’t mean you should fly a jetliner full of passengers down to Florida.”

But ophthalmologists can only convey their concerns when they’re given enough time. By the immaculate design of 18 lobbyists, the ophthalmologists knew about the Kentucky bill just 12 hours before it entered a Senate committee (bypassing a customary 72-hour holding period), and sailed through that committee to the Senate floor the next day. The whole process, from the bill’s first public posting to the Governor signing it into law, took 17 days, bypassing hundreds of other bills filed well before it. “It was a juggernaut. It was an advancing force that seemed to crush everything under its path,” Tom Loftus said on the KET program Comment on Kentucky.

Dr. Van Meter says he and his colleagues got 10 minutes total to make their case at an informational hearing put together at the last minute in the Kentucky Senate.

“The people pushing the bill to me looked like your dog when you come into the kitchen and he’s taken a piece of meat of your plate,” Dr. Van Meter told me. “He just looks guilty as sin, but he’s sitting there smiling with big eyes like nothing in the world ever happened.”

The bill itself looks like a rush job. It even includes an anatomical error. It prohibits optometrists from injecting into the posterior chamber of the eye (nobody can, it’s too small a space). Presumably that line meant to state that optometrists cannot inject into the posterior segment of the eye, which includes the vitreous. Because of the sloppy writing, now optometrists can inject into the posterior segment, using drugs like Lucentis to treat macular degeneration. The bill also excludes optometrists from performing two common excimer laser corrective vision procedures, LASIK and PRK, but leaves out another common procedure, LASEK.

Dr. Ben Gaddie admits the LASEK loophole exists, but he expects the optometry board won’t allow excimer laser procedures at all, following the spirit of the legislation if not its wording. However, he’s not on the optometry board.

Dr. Van Meter and other state ophthalmology leaders sat down with Kentucky’s governor to make their case as he weighed whether to sign the bill that had arrived on his desk with such urgency. They were a little flummoxed when it became apparent the governor had little issue with the idea that providers who didn’t go to medical school would be doing surgery. “He seemed to think that was okay,” Dr. Van Meter observes.

I asked the governor, who was on the road attending the National Governor’s Association Winter Meeting in D.C. this weekend, whether he was now pioneering the way for other states in redefining optometry. He’s making no such stand. Beshear based his decision “solely on what is best for the people of Kentucky. Under that framework, improving access to health care of all kinds is a priority for Kentuckians. Other states must make their own determinations for what is best for their citizens,” he wrote in an email.

Elaborating on the access issue, Beshear wrote, “there are fewer ophthamologists in Kentucky than optometrists, and at times, it may be easier for residents (especially in rural areas) to get access to an optometrist for needed eye care. There will be times when citizens will require the services of an ophthalmologist; however, this legislation will allow Kentuckians to have more options in accessing proper eye care.”

Naturally I wanted to know whether the governor would choose the care of an ophthalmologist or an optometrist should he need an eye surgery now in the optometry’s purview. Maybe he’ll simply pick the geographically closest provider, like he expects the disadvantaged Appalachian citizens of his state will do? He didn’t answer that one.

What’s optometry’s end game, if the field sees itself as the primary care providers for the eye? ”It’s hard for me to fathom that the end goal of the organized profession of optometry is to go in and do routine intraocular surgery like retinal disease or cataract surgery or incisional glaucoma surgery,” says Dr. Ben Gaddie. He believes that the minor surgical procedures with scalpels and lasers Kentucky now allows fit into the “primary care” mold.

It sure sounds specialized to me. The eye is part of the central nervous system. I don’t know too many primary care docs who do a little bit of neurosurgery or plastic surgery on the side. There’s a reason the rest of medicine organizes itself into cardiologists and cardiovascular surgeons, neurologists and neurosurgeons, and so on. There’s a reason you want a surgeon to do surgery. They do a lot, and they do it well. It’s worth a little drive.

“I give the optometrists an A+ in politics,” says Dr. Parke of the ophthalmology association. “I may give them an F in being an effective advocate for patient safety and quality of care.”

Ford Vox is a physician and medical journalist who has written for Reuters, U.S. News & World Report, and Newsweek. This piece originally appeared in The Atlantic, and is reprinted with the author’s permission.

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  • Fam Med Doc

    My condolences to my Optholmology colleagues. I see the same problem in primary care: mid-level providers who feel competent to be the primary care physician (yes, I know they would say “providers”, but they mean to act as the SOLE person giving the primary care). It’s unfortunate because patient care will suffer (I see it all the time in primary care). The pilot analogy is excellent: you can’t always count on good weather & optometrists (and Nurse Practitioners & PA’s) aren’t trained enough to deal with complications. But more astute patients will of course shy away from optometrists & mid-levels. They are a dangerous group.

  • Angela Caffaratti, MD

    It seems very hard to convince the politicians that what you don’t know can harm. They spell out this or that that non-physicians can or can’t do, but you must have wisdom to know what you should do. If you have a hammer, everything looks like a nail.

  • Observer

    As someone who worked at an internationally renowned ophthalmology teaching hospital for more than 15 years, Dr. Vox’s post is over the top. I am neither an optometrist nor ophthalmologist, but collaborate with both and therefore, may bring some balance. This war between the disciplines is not about quality, but rather money and capturing the consumer’s dollar.

    Ophthalmologists like to share disaster stories at the hands of the optometrists. But they rarely mention their own. Like the seasoned retina specialist, so focused on the macula, that the intra-ocular pressure was never measured (50mm Hg). Or the cornea specialist, so focused on the corneal sutures, that the retinal detachment was missed. Or the ophthalmology resident who thought it would be a great idea to take photos of the penetrating nail gun injury and requested the patient to look “up, down, left and right” taking awesome photos, but not having the clinical skills to realize that the nail was shredding the retina (eventually resulting in an enucleation). Is that good quality eye care?

    The majority of eye doctors (MD’s, OD’s) provide very good clinical care and occasionally they don’t. I’ve learned, that this fight is really not about clinical care, but rather competition for the dollar. Ophthalmologists don’t want the OD’s infringing on their revenue streams, and faithfully pull-out the “quality” card to disparage OD’s in the public eye. OD’s on the other hand, want to expand the scope of their practice. It’s about money, and both sides know it.

    • Vox Rusticus

      Neither optometry nor ophthalmology is immune from error, or negligence. But the issue in Kentucky is more than merely about two professions competing for patients. It is about optometry appropriating for itself (with the help of friendly state legislators) the right to define what qualifications are necessary to do surgery, in a state where those qualifications were already defined, at least for physicians. The legislation essentially allows optometrists to do any kind of surgery their board of optometry does not expressly prohibit (not permit, prohibit) That is surgery on any organ, not just eyes. They are allowed to open surgery centers, staff those centers with whomever they please and the only agency they are accountable to is the Kentucky Board of Optometry. The Board of Medicine, which has authority over every medical specialty, including all surgery specialties in that state, has no say as to what optometrists are allowed to do when they do surgery. As things stand, no kind of residency, nor any demonstration of surgical case experience stands in the way of an optometrist performing surgery of just about any kind. The parsing of LASIK from LASEK is laughably irrelevant.

    • Fam Med Doc

      Dear Observer,

      I’m an observer too. I have observed quite the opposite in primary care which is struggling with the same issues as my Optho collegues. Non-physicians such as Optometrists, Nurse Practitioners & PA’s cause alot of harm. Yet with clever & aggressive lobbying, they are increasing their scope of practice, to the detriment of patient care. And I am skeptical of your credentials of “collaborating with both” Optometrists & Opthamologists. This doesn’t make you, nor I, an expert in having a well informed opinion in knowing the proper scope of practice non physicians should have. Opthamologists are really the only ones capable of such an informed opinion. As a primary care doctor, I trust my Opthamologists when they say Optometrists are getting out of their league. Optometrists can create complications, yet are untrained in how to manage them. It’s just like the Nurse Practitioners & PA’s who are in primary care: they create complications but are unable to manage them. It’s simply dangerous.

      Everyone wants to be a doctor. No one wants to go to medical school.

      • ninguem

        Fam Med, have you been approached by optometrists for “collaborative” arrangements, which basically means they play ophthalmologist for diseases such as glaucoma, and you take the medicolegal hit for any misadventure.

        • Fam Med Doc

          Dear ninguem,

          No I haven’t. And I wouldn’t accept if such arrangement was offered. I’m a physician & only have professional relations w other physicians. Optometrists are not physicians. Neither are mid-level providers.

          Have you?

          • ninguem

            No, I had an optometrist call about that, I turned him down, to put it mildly.

            The other one I get a fair amount, is naturopaths ordering massive amounts of expensive, unnecessary and duplicative tests……and telling the patient to ask me to order them.

            Then idea is the patient gets them “free”, and I’m on the hook with the insurance company for unnecessary testing.

            I’ve turned them down, but I deeply resent the naturopath manipulating the situation to make me the bad guy.

    • Joe

      Observer, your argument only works against the optometrist. While you may cynically interpret the motivation behind physicians group’s statements regarding differing level and manner of training, at least the physician’s have that point to stand upon. Do optometrists have any leg to stand on here? I don’t see one. The convenience argument is far from convincing. If there was such a dire need, such aggressive lobbying and back-room politics would not be necessary.

  • http://www.mdwrites.com MD

    I though that education and training is the only way to define your practice? Guess not. With some strategic donations, and lobbying, there are no limits! Broadening optometrists scope of practice through laws is a very bad precedent in my opinion.

  • Brian Loveless, DO

    Our med-legal professor in med school always reminded us that we are granted the right to practice not by act of God but by act of legislature.

  • skeptikus

    Why don’t you let evidence (rather than self-interest) guide your views? Let’s see in 5 years whether there are any more complications/ suits arising from optometrists doing LASIK.

    • Family Medicine Doctor

      thats a dangerous proposition. so what if the outcome after 5 years is alot of complications and patients hurt by Optometrists? What do we say to them then? Sorry, but it sounded like a good idea…

      • ninguem

        I had a patient who went to Mexico for cheap dental care. Now, if he could afford the travel, he could afford local dentistry, so don’t cry poverty. Mexican dentist had a major misadventure with major complications, now there’s a complicated fix.

        Every dentist…….and I mean every single one in a 100 mile radius…….told him to get it fixed in Mexico. And I don’t blame those dentists, not one bit. He finally found a University dental school in the next state that took him in, and it looks like used him as a bad example of what not to do.

        I kept getting asked to practice outside my field, play dentist or oral surgeon to manage the associated problems. Sorry, I’m not going to risk my license because you don’t want to travel 200 miles and wait in line at the University.

        So, fine. Let the optometrists play ophthalmologist. But don’t ask the ophthalmologist to clean up their mess.

    • Kristin

      Or we could even go really crazy and design a system where we can monitor outcomes of all procedures, by all providers, for all patients. The computing power exists–what doesn’t is the technological infrastructure (compatible EMRs) and the mandate (to make providers record the information and send it for analysis to a centralized data-analysis department).

      If we wanted to, we could measure performance in a quantitative, meaningful way. We could transform medicine from being at best based on a few well-designed studies and at worst a mish-mash of half-remembered folklore into a truly evidence-based practice. Why don’t we?

      Is it because we’re afraid of Big Brother? Because doctors are reluctant to adopt EMRs? Because the current system is not, in fact, based on helping people get better from acute illnesses and effectively manage chronic ones? Because insurance companies are tethered to short-term payoffs rather than long-term solutions, and their lobbying power is exceeded only by their soullessness? And if these are all problems, how do we fix them?

      This is my axe to grind, yes. Research can’t solve everything, but it can solve an empirical question. Medicine is full of empirical questions, and arguing them as though they were opinion questions instead gets us nowhere.

  • skeptikus

    Family Doctor: Dangerous? what do you mean? How many therapies have been tried without sound empirical basis only to be rejected as dangerous or ineffective: hormone replacement, tonsil removal, mother attachment for autistic children.

    To use your own language, “What do we say to them then? Sorry, but it sounded like a good idea.”

    • Fam Med Doc

      Dear Skeptikus,

      The difference is the medical community as a group (that’s the important point here) decided on a certain medical standard. That medical standard was arrived at with significant scientific though & experience via a consensus of the scholars of that day using the scientific methods available to them at that time. Yes, your examples are correct, that medical standard has changed for the specific examples you listed. But the point you miss is NON PHYSICIANS are changing the medical standard by BUYING VOTES in state legislatures. That is not a medical community painstakingly going thru the data and arriving at a consensus of physician experts.

      Big difference. Huge. And patients will be harmed.

  • PAULMD

    This would be a funny hypothetical situation if it weren’t for the fact that it is true. The optometrists of Kentucky bought a legislature and governor and legislated a competency that they don’t really have.

    What next?

  • Michael Farley MD

    I am a primary care doc (pediatrician) who retrained to become a subspecialty corneal ophthalmologist. When I entered private practice, I joined a senior well-known ophthalmologist who told me that “We practice medicine not by virtue of our training, but by a piece of paper politicians grant to us”. That was in 1985 and how prophetic that statement has turned out to be. I gained a lot of experience performing corneal transplants in patients with corneal ulcers from contact lens wearing. Many of those patients were mismanaged by optometrists who did not recognize the aggressive nature of those infections. Yes, there are excellent optometrists as well as lousy ophthalmologists. But there is a quantum jump in clinical acumen, to say nothing of surgical skills with proper training, between ophthalmologists and optometrists.
    To not hold optometrists accountable to the same standards of medicine as ophthalmologists and answerable only to a state board of optometry, not a medical board, is negligent behavior on the part of politicians.

    • ninguem

      Been there, done that, with the nurse practitioners and the naturopaths. They’re not held to medical standards of care. Misadventures that would get a doc in trouble, the naturopath just skates off. I know it because they were my patients hurt.

  • Richard Bensinger, MD

    Optoms would like to go to medical school but have found an easier way – get credentials by lobbying the legislature. Optoms do not have a board exam – they do not even trust their own knowledge to allow this. They are exploring this but in the past have always voted it down in their national assembly. I have always said, “You want to do what I,an ophthalmologist, do? OK – take my board examination.” I have talked with optoms and doubt that all but a handful of them would come close to the minimum score for passing my board. One other issue. In all situations where in a given State, privileges are legislatively doled out to optoms, the supervision is handed over to Boards of Optometry.
    Can you imagine what a conflict of interest this represents?

  • skeptikus

    And why doesn’t the same conflict of interest exist when medical board supervise opthamologists?

  • http://fertilityfile.com IVF-MD

    Let me see if I understand this correctly. So the argument here put forth by the optometrists is that outcomes speak for themselves and that optometrists should be legally allowed to perform surgery if they demonstrate that their outcomes are about as good as those of the MDs, regardless of their degree. Correct?

    Before I offer my opinion on that, I would ask the optometrists this question. Suppose an MD decided to open up some low cost satellite kiosks in malls to dispense eyeglasses and he meticulously trained some smart techs to perform refraction measurements. So these non-O.D. technicians get really good at asking the patients, “Which lens is clearer? Number 1 or number 2?”. For the sake of argument, let’s say that these techs were foreign optometrists who successfully practiced for years in their home countries. Then can prove that they are able to come up with the correct calculations and make a pair of eyeglasses for the patient at a fraction of the cost of what the optometrists charge.

    If they could establish that their outcomes are as good as those of the optometrists, would the optometrists be OK with it being legal for these people to perform their services? Bear in mind that the mistake of being off by a half diopter pales in comparison to the mistake of a surgical complication.

    So if optometrists want to do surgery, then should skilled (but non-US-degreed) personnel be allowed to do simple refraction? It would be important not to be hypocritical, no?

    • marc

      It’s worse than hypocritical… it’s pure restraint of trade based on lies. While ODs will equalize the discussion by saying its all about money on both sides, at least the MDs have a real safety issue to deal with when discussing medicine and surgery, and while OD’s and MD’s both make mistakes, it’s all about the rate at which these mistakes are made.

      On the otherhand, the measuring and selling of glasses is a completely safe endeavor equivalent to selling cameras, telescopes, binoculars, and reading glasses. Yet this activity is artificially restricted not only by one (the optometrists) but often by TWO useless boards (the opticians) all under the guise of safety!

      FYI: JAMA May 10, 2006 – 14 million people in the US can’t see well because of unaffordable eyewear.

  • FMG

    No doubt almost everybody prefers an MD Ophthalmologist to take care of their eyes. The problem is that there is not enough coverage in some areas of the country because there are not enough ophthalmologists. Rather than allowing OD to do this I would prefer that the law would let foreign graduate ophthalmologists to take the board tests of ophthalmology, and if they can pass this tests give them license to practice in those rural areas of the country.