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 last week 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."

interesting article! apparently the US people want us to copy from has the same issues we are trying to sort out here.
the boundaries that seperate one job from another are becoming HAZY. i will post a few of the comments that followed that article here;

brian(an ophtalomologist) says
"This is not an access to care issue. If you believe that, they have successfully pulled the wool over your head. Did you know quite a few Optometrists actually had aspirations to become M.D.s but failed to get into medical school. Did you know the academic rigor of getting into Optometry school is only a fraction of what it takes to get into medical school? There is an undercurrent of embitterment among Optometrists. The reality is if you want to do surgery, you should go to medical school. If you couldn't get in, there was clearly a reason for that. Using a legislative bill to get a backdoor degree into surgery is both ethically and morally reprehensible. Unfortunately, the proponents will only see the light after patients develop blinding complications from Optometrists doing surgery. It's not an if. It's a when. I hope that won't be you"

maino(an optometrist) says
"Remember it is not necessarily the number of ODs or OMDs that is the issue...but rather their accessibility. Optometry tends to be in places that ophthalmology is not...providing better access"

jorgenharris(most likely a neutral) says

"

You're conflating two very different questions here. The first is whether we need more people certified and trained to perform eye surgery, and the second is whether allowing optometrists to perform some of those surgeries is the right way to increase access. I'm no expert on health related matters, but here is the evidence I've been able to dredge up on the first question:

From 1970 to 2000, the number of Opthamologists practicing in the United States has increased from 9/100,000 people to 11/100,000 people (A 22% increase). As context, the total number of physicians practicing in the US has increased from 155.6/100,000 to 279.8/100,000 (an 80% increase). (http://www.bls.gov/oes/current... As we as a country have been discussing for a while now, health care costs have steadily increased over this time--from 1980 to 2000, physician services per capita increased more than fourfold (http://www.census.gov/prod/200....

Now, it's possible that this increase just hasn't been seen as strongly for opthamology, but my guess is that the exact opposite is true, since many of the most popular eye surgeries (lasik only became available in 1989).

This is a long winded way of saying that I really, truly doubt that we don't have an access to care issue. The number of certified opthamologists have grown slowly at a time when the breadth of possible eye surgeries, the wealth of the country and the willingness to pay for medical care have grown quickly. Unless rural Kentucky had a surplus of opthamologists back in 1970 it's hard to credit that there are plenty of opthamologists.

As to the question of whether certifying optometrists to perform eye surgery is a good solution, I really don't know. It would probably be a much better solution to increase the number of residency programs for opthamologists, and for the AMA to certify more med schools generally. I'd also love to see foreign medical practicioners have an easier time recredentialing in the United States, and immigrating here in the first place. But until I see some actual evidence that Optometrists have a significantly higher failure rate than opthamologists in performing more basic surgeries, I'm leaning toward expanded access.

By the way, of course some patients will get blinded by optometrists if we allow them to do surgery. I'm sure there are plenty of patients getting blinded by opthamologists all the time. When it happens, it will make a great scare story, and I can only hope we all take the time to look for context"

brian says;
"Dear Jorgenharris:

Your rationale is logical; however, you are being duped by the Optometrist's and their propaganda. Poor access to care was the major impetus behind this legislation. But this is far from the truth. And on the contrary. I am not "conflating" these issues. Rather, they are intimately intertwined: access and quality of care.

The reality is that I know many Ophthalmologists around the country and I know for a fact that it is not like their practices are closed to new patients. In other words, they are not at max capacity and can see more patients. The issues are whether or not physicians can afford to see patients when reimbursements are being slashed, but that is a whole different issue about health care policy and requires a different subject header.

The Optometrists want you to think they are being altruistics but this is not the case. Let me give you an example. Several years ago, legislation was proposed which would allow Optometrists to take care of postoperative (after surgery) patients. This was proposed because Optometrists and even some Ophthalmologists felt that patients in rural communities would be better served by seeing their local Optometrist after cataract surgery rather than by their Eye Surgeon/Ophthalmologist who was a 100 miles away. This passed legislation and is called comanagement. This was unprecedented and mind you, no other surgical specialty has moved to such a model because it is (IMO) absurd to have a non-surgeon manage after-surgery patients. In other words, after brain surgery, heart bypass, hip replacement, no one goes to see a nurse practitioner, physician assistant, not even a primary care physician. They are managed by their surgeon, which is the way it should be. Sorry…I digress. Remember, the intent of comanagement proposed to the legislature was to alleviate this access to care issue. In other to make this work, the comanaging Optometrist receives 20% of the surgery fee. Why is this fee splitting an issue? Well, this legislation which was intended to help rural patients, is now being used by Optometrists as a leveraging tool against Ophthalmologists. In other words, even in non-rural cities (no access to care issue), Optometrists refer cataract surgery to Ophthalmologists out of town even though there may be a competent Ophthalmologist down the street. This directly contradicts the core intention of the comanagement legislation. Please believe me when I say this is real and is pervasive throughout the U.S. My point is that Optometrists have used this access to care argument when petitioning the legislature before when in fact the bottom line is that they push to get these privileges to make more money. That is the bottom line, not access to care. Now an Optometrist will argue that they know how to manage after surgery patients. I will not argue whether or not this is true because it is less relevant that they can or cannot. What is more important is how they got that privilege. The original intent has been twisted from altruism to pocket padding.

As far as allowing non-medical doctors to perform surgery. Your argument sounds reasonable: if there are not enough doctors, just create a bunch of laws which allow non-doctors to perform doctor duties and bypass the intensive training process. Well, let’s make an analogy using teachers who have been in the media a lot lately. According to your logic, if the unions and teachers are picketing and refusing to work under new terms, why don’t the legislators simply fire all teachers then promote all teachers aids, assistants, or people with 2 year associates degree. i.e. Anyone with less qualifications than a teacher and promote them to teacher status. Let them have all the authority and privileges normally given to teachers and let them teach our children, the future of America. Do you think I’m stretching it? Well, with this logic we can pay these teacher-wannabes a whole lot less than the unionized teachers and cut the budget deficit. But of course, we compromise the quality of education in doing so and no one would propose something this absurd, right? Now please don’t misunderstand. I am not saying I am for or against teacher unions. I am just using this as an example. If some of you are offended by this, please reflect for a moment. How in the world does it make sense to allow someone with lack of surgical training and experience to cut on patients in the name of “access to care”. If this is the case, why not take all professions and “dumb-them down”. Drop the bar so that anyone can do surgery, be an astronaut, physicist, engineer, in the name of “we just need more of them”. Makes no sense to me"

gschultz(an optometrist)says


" you are obviously under educated on this topic or just ignorant and need to get your facts straight. If I was a patient in rural Kentucky in angle closure glaucoma ( a very painful condition) that can often be remedied by a simple laser procedure in minutes, which is literally an extension of a procedure that optometrists perform every day (gonioscopy), I think people would be lining up to have a competant optometrist perform their laser procedure, rather than travel 3-5 hours in excrutiating pain to see an ophthalmologist. Optometrists already have the right to treat this painful glaucoma medically, and I have successfully treated many hundreds of these cases in my carreer.The truth is it depends on your training, and certainly optometrists performing these procedures would be the most highly trained in the field. Your logic is insane. Do you have any idea how many people have their anesthesia delivered by nurses (CRNA's) nationwide or how many patients have their diabetes managed quarterly by a Physicians assisstant or Nurse practitioner with essentially no oversite by a qualified physician? Optometrists with residency training have far more training and education than both of those professions, yet know one seems to care about that. This is not about being qualified, its about politics and a turf war. I have worked in ophthalmology as a medical optometrist treating complex and sight threatening diseases for 17 years, and have faired extremely well, and I dare say better than some of my ophthalmological colleages. I have yet to see a patient code from a yag capsulotomy or PI. Optometrists are not trying to push IV anesthesia either, that is higher risk and is the domain of trained professionals some who are MD's and some not.

Optometrists are not "playing doctor", they are doctors with 4 years of post-graduate training and in many cases residency or fellowships for extra experience. They have systemic pharmacology and more ocular pharmacology training in their curriculum than do MD/ ophthalmologists. I have worked with many ophthalmologists in every subspecialty , some good some not so good, and if you think your safe just because the person behind the mask has MD after his name you're delusional. Most MD's I know spend about 2 minutes with each patient in order to maximize their patient load and income, and if you think thats quality care your opinion doesn't matter. I can tell you there are just as many horror stories about ophthalmologists making misdiagnoses and mistakes that have blinded people ( I have personally been involved with two such cases and I'm sure OD's across the country could site many more) so the two anecdotal cases sited here in the article are nothing. People who live in glass houses should not throw stones"


stevein says
"I call BS on that. Your training concerning medical and surgical management pales in comparison to that of an ophthalmologist, as does your ocular pharmacology education. And if you have yet to see a pt suffer a systemic complication from a laser procedure, that's only because YOU HAVEN'T DONE ANY. Such a statement highlights the fundamental problem optoms can't seem to grasp: YOU DON'T KNOW WHAT YOU DON'T KNOW. You want to be a surgeon? Go to medical school. What has been done in your name in KY--essentially buying the votes of the entire state legislature, and the governor--is appalling, and to the detriment of KY's citizens"

Wannabes on the prowl everywhere sha! Genuine doctors beware. Abeg i don tire for all dis kind matter...the poor will always go for the cheap and fake while diamonds last forever!

Even in Yankee. They went as far as purchasing the legislation. Its interesting let's see how this pans out.

I expect johesuites to come here and start quoting international best practices.