Viewpoint FROM THE CHIEF MEDICAL EDITOR

An Open Letter to Optometry

Larry E. Patterson, MD

Many years ago, before I started in practice, organized optometry led a charge, state by state, to change the laws so that they could use diagnostic medications. They emphasized that they had no interest in treating disease—they just wanted to be able to better diagnose problems. Organized medicine in general, and ophthalmology in particular, opposed them, but eventually lost.

Later, about the time I was a resident, optometry led a charge, state by state, to change the laws so that they could use therapeutic medications for “simple things” like conjunctivitis. They emphasized that they had no interest in treating serious diseases—they just wanted to be able to take care of simple, common disorders they saw in their offices. Medicine and ophthalmology opposed them, and lost.

As I entered practice, optometry led a charge, state by state, to change the laws so that they could use medications to treat more serious diseases like glaucoma and corneal ulcers. They emphasized that they had no interest in treating surgical problems—they just wanted to take care of anything short of surgery. Medicine and ophthalmology opposed them, and lost.

A few weeks ago, optometry led a charge in Kentucky, building on a similar one in Oklahoma years ago, to change the laws to allow them to use their optometric skills to perform many “minor surgeries” of the eye and adnexa, including laser treatment for YAG capsulotomy, ALT and iridotomy, as well as surgical injection and incision of chalazion. (While the new law doesn't allow for treating cancers, often it's not until the pathology report comes back that you realize you've indeed operated on a cancer.) Proponents emphasized that they had no interest in performing more serious surgeries, such as cataract, they just wanted to provide these “simple” surgical procedures to the patients they saw in their offices. Medicine and ophthalmology opposed them, and lost.

Most troubling for us about the bill is that it's a bit open ended: the state Board of Optometric Examiners, not the legislature, will determine the future scope of practice for optometrists.

The argument in Kentucky essentially said that lots of rural patients don't have access to an ophthalmologist, so someone who knows a lot about the eye but has no medical school or surgical training should be able to do these procedures. This argument, along with boatloads of money and lobbyists, won the day for optometry. Nearly every major newspaper in Kentucky opposed it, and there was unprecedented outcry about the legislation having been hurried through with minimal debate or discussion.

Financially, it makes no sense for a rural optometrist to do any of these surgeries. The reimbursement is quite poor. After you add in the cost of YAG, SLT and/or argon lasers, the increased malpractice overhead, cost of actually learning how to do these procedures and the enormous OSHA requirements, you'll most likely lose lots of money unless you are seriously overutilizing. No, the law only makes sense if you've got your eyes on LASIK, cataract and perhaps other surgeries.

This time, medicine in general and ophthalmology in particular may have finally woken up. We see where this is headed and we're drawing a line in the sand.

I can't sit here and say an optometrist can't capably perform a YAG capsulotomy. I think with a few weeks of training, I could teach any one of my technicians to do the same. But there has to be some value to my four years of medical school, followed by the year of internship in general medicine, as a background to the three to four years of ophthalmology residency training. You'd really need to have experienced that training to truly understand what it means. Years of surgical training is exactly that—years of surgical training, not a weekend course.

So here's how I see this scenario playing out. In my own state of Tennessee, and many others across the nation, optometrists are being encouraged to spend huge amounts of their own personal wealth to allow them to do surgery here, just like in Kentucky. But we ophthalmologists are being encouraged to spend huge amounts of our own personal wealth to stop the optometrists from repeating what they did in Kentucky. And now that you've awakened a sleeping giant, you'll get very little accomplished and all of us will be a whole lot poorer. Lobbyists, on the other hand, will make out like bandits.

We are not your enemy. If you've read my editorials through the years, you know I'm quite optometry friendly. In my practice, I have one of the highest optometrist-to-ophthalmologist ratios in the nation. I've got very smart and well-trained optometrists with whom I am very proud to work. And interestingly, I've never met even one optometrist who expressed a strong desire to do these surgeries. Most ODs I've talked to say something like, “If I'd wanted to do eye surgery, I would have gone to medical school.”

If I were an optometrist, I'd be much more concerned about organized opticianry blindsiding me and getting laws passed to allow them to refract without going to optometry school. With all the debate about the high cost of healthcare, don't think for a moment that they couldn't hire a bunch of lobbyists and work back-room deals to make that happen. You'd be kidding yourself if you denied that's how optometry expanded its scope of practice. And, hey, what's good for the goose is good for the gander.

So here's what I suggest: quit while you're ahead. You got therapeutics. You won. Yes, a few states don't let you use them, and I'm sure we'll keep fighting you until you win there as well. We can argue it all day. But in the end, really, you won that one. So let's leave it at that, and have a truce. Quit trying to be surgeons. Encourage those of you who have a hankering to operate to apply to med school and do it the right way. The rest of us? Let's use our money together, fighting for what's really important, our patients. OM