By Stephen Barlas
Ophthalmology is at a critical juncture. Optometrists have won full surgical privileges in Oklahoma and limited privileges within the VA. Fortunately, there is still time to reverse these decisions, and ophthalmology’s leaders are working furiously to ensure surgery by surgeons. The greatest hope for our patients and profession? That all Academy members realize that their input is needed.
When his cell phone rang at 6 p.m. on June 23, Pat Eddington was already a man in a hurry. The lobbyist for the Academy was on the verge of walking out of his office to attend a political fundraiser after a day of pounding the hallways of the three U.S. Senate office buildings in an effort to line up support for a crucial vote that evening on the Senate floor. Sen. Peter Fitzgerald (D-Ill.) would be offering an Academy-sought amendment to a defense bill allowing only a licensed medical doctor or licensed doctor of osteopathy to perform eye surgery at a Department of Veterans Affairs facility. The amendment was based on the “Veterans Eye Treatment Safety (VETS) Act of 2003” introduced in November 2003 by Rep. John Sullivan (R-Okla.) in response to the granting of surgical privileges to an optometrist at a VA hospital in Kansas.
But an aide to Sen. Fitzgerald was on the other end of the line. He told Mr. Eddington that Sen. Carl Levin (D-Mich.) had placed a “hold” on the Fitzgerald amendment. That meant it could not be brought up for a noncontroversial, unanimous consent vote. An hour later, the same aide called again. Now a Republican senator was raising objections. Fortunately, Cathy Cohen, Academy vice president of Government Affairs, happened to be having dinner with that senator and others at just that moment. Mr. Eddington, now at dinner at a downtown D.C. restaurant, called Ms. Cohen. She talked with the senator, and he agreed to release his hold. By 9 p.m., all Senate Republican opposition had been erased. Still, there was Sen. Levin—and now, Sen. Barbara Boxer was tossing legislative roadblocks in front of the Fitzgerald amendment.
With those two Democrats refusing to allow the Academy-sponsored bill to come up for a vote, the Academy decided not to force the issue that evening. A controversial floor fight was not in the best interests of ophthalmologists. Nor was it worth jeopardizing the significant political headway the Academy had made during the 108th Congress, gains that would serve as momentum for new efforts to blunt the aggressive drive by optometrists to become de facto ophthalmologists. Instead, on July 22, the five senator sponsors of the Fitzgerald amendment opened a second legislative front in the battle for “Surgery by Surgeons” through the introduction of a stand-alone Senate version of the VETS Act.
Optometry’s efforts to achieve medical privileges have been going on for decades. State legislatures have widened optometry’s scope of practice bit-by-bit until services like prescribing medication seem like an optometric right, not a patient wrong. Then in a 1998 vote that caused patient safety advocates everywhere to do a double take, the Oklahoma legislature allowed optometrists to perform anterior segment laser surgeries. But the latest instance of scope of practice expansion—which occasioned the Fitzgerald amendment—was unprecedented: It took Oklahoma state law national.
Using that 1998 law as a lever, an Oklahoma optometrist at the Robert J. Dole Veterans Affairs Medical Center in Wichita, Kan., convinced the facility medical director in 2003 to acquire an ophthalmic laser and “privilege” her for anterior segment laser surgery and lid surgery. While it turns out that she is one of at least three optometrists able to perform laser surgery in the VA, her high-profile case may go a long way toward smoothing the way for other Oklahoma-licensed optometrists to conduct laser surgery at VA facilities around the country.
Then in 2004, back in the state of Oklahoma, optometrists pushed the envelope, arguing that the 1998 law allows them to perform noncosmetic lid surgery because that law only rules out laser surgery on the retina, LASIK and cosmetic lid surgery. However, on April 6, 2004, Oklahoma Attorney General W. A. Drew Edmondson disagreed with that interpretation. He said the Optometry Board would need “statutory authority” from the Oklahoma legislature before it could certify optometrists to do more than the PRK and anterior segment laser procedures endorsed by the 1998 law.
That’s when the Oklahoma legislature took a second step in that very wrong direction, passing a second bill in May 2004 specifically endorsing “surgery” as an optometric right. What’s more, it boldly stated that the Oklahoma Board of Examiners in Optometry, and only that Board (not the state medical board, for example), was responsible for defining optometric scope of practice. Those provisions were added to a pharmacy bill while it was in conference between the Oklahoma House and Senate, the legislative equivalent of “the dead of night.” There were no hearings on the optometric provisions in HB 2321. “The new Oklahoma law is the most egregious example yet of optometry using state legislatures to expand their scope of practice,” stated H. Dunbar Hoskins Jr., MD, executive vice president of the Academy.
After the bill’s passage, David Cockrell, OD, FAAO, president of the Board of Examiners in Optometry, said in Review of Optometry that the bill did not expand current optometric scope of practice. Rather it was necessary, after the attorney general’s April judgment, to clarify that optometrists can perform epilation and punctal plugs, two procedures classified as surgery by the American Medical Association’s CPT code.1
Oklahoma Ophthalmology’s Position
Ann A. Warn, MD, MBA, president of the Oklahoma Academy of Ophthalmology, doesn’t have a problem with optometrists doing epilation or punctal plugs. Nor do most ophthalmologists. But if that is the extent of the scope expansion desired by Oklahoma optometrists, then she wonders why didn’t they have those two procedures, and only those two procedures, written into HB 2321? She said, “It’s really quite simple: Surgery should be performed by surgeons who graduate from a medical or osteopathic school, complete a one-year hospital internship and then complete a three-year residency specialty in eye disease and surgery.”
Patient safety motivates ophthalmology’s opposition to optometric surgery, not any economic threat. “This is not a financial issue,” said Dr. Warn. “We are concerned about the quality of care for the citizens of Oklahoma.”
In fact, said Cynthia A. Bradford, MD, secretary of State Governmental Affairs for the Academy and an Oklahoma ophthalmologist herself, her practice has not been impacted at all by the 1998 law that sanctioned optometrists performing PRK laser surgery, YAG capsulotomies, argon laser trabeculotomies for glaucoma and laser peripheral iridotomies for narrow-angle or angle-closure glaucoma.
Dr. Warn agreed that her practice hasn’t been hurt, either, because of the small number of optometrists doing those laser procedures, and the fact that most optometrists exercising their 1998 privileges are concentrated in Oklahoma City and Tulsa, even though optometrists argued for laser surgery rights based on the need of rural patients.
Medicine Comes Together
The patient safety concerns voiced by ophthalmologists stem from the diametric differences in training between optometrists and ophthalmologists. “Optometrists want to set up a parallel profession without having to get the medical training we get,” said Dr. Bradford. That was the refrain echoing in Oklahoma City on July 11 during a special session called by the Oklahoma Academy of Ophthalmology. The meeting took place while advertisements paid for by the American Academy of Ophthalmology filled the radio airwaves. One ad shed light on the difference in training between optometrists and ophthalmologists. The other asked why Oklahoma is the only state in the union to give optometrists the right to do surgery.
Allan D. Jensen, MD, president of the Academy, flew in from Baltimore for the Oklahoma City meeting. “Oklahoma ophthalmologists recognize the Academy is very serious about this because 12 members of the board of trustees attended that meeting,” he said. Herman I. Abromowitz, MD, an American Medical Association trustee, was also there. The AMA is concerned about the impact of the Oklahoma 1998 and 2004 laws in a broader sense, because they are just another example of nonphysicians reaching for physician practice prerogative. For example, in April the Louisiana legislature passed a bill in near-record time allowing psychologists to prescribe drugs. “Proponents of this bill are putting patients’ lives at risk,” said Marcia K. Goin, MD, president of the American Psychiatric Association. “Psychologists are not medical doctors, and, under the bill, they would not be required to get the training necessary to safely prescribe potent medications.” Dr. Abromowitz alluded to this “parallel profession” epidemic at the July 11 summit. “Since the debate concerning the expansion of the practice of nonphysicians implicates vital issues of state public health and safety, it affects all physicians and their patients,” he said. “As such, whether it’s optometrists wanting to perform surgery in Oklahoma or psychologists seeking to prescribe psychotropic medications in New Mexico and Louisiana, the AMA believes it must be strong in its conviction that unacceptable expansions into the practice of medicine must be prevented.”
The Oklahoma City meeting reinforced the Academy’s commitment to the Surgery by Surgeons campaign that opposes efforts by any state legislature to expand optometric scope to include optometric surgical privileges.
A Look at OD Training
Are optometrists in Oklahoma adequately trained for noncosmetic lid surgery? What about for laser surgeries such as YAG capsulotomies, argon laser trabeculotomies for glaucoma and laser peripheral iridotomies for narrow-angle or angle-closure glaucoma?
Northeastern State University, the only college of optometry in Oklahoma, has included use and theory of lasers in its curriculum since 1988, according to George Foster, OD, dean of the school. In the current school year at Northeastern, for example, the 26 fourth-year students, 12 residents and 22 faculty will perform “several thousand” surgical procedures, which include anterior segment lasers and minor office-based procedures. He declined to say exactly how much surgical experience each student receives nor how many laser surgeries a student might perform during the four-year curriculum.
For practicing Oklahoma optometrists who wished to become certified in laser surgery last spring, Northeastern and TLC Laser Eye Centers offered a two-day course. The marketing brochure stated that training would include “14.5 hours didactic, four hours clinical with written exam, FDA laser course with wet lab for either Visx S4 Custom Vue or LadarVision Custom Cornea.” In addition, “to complete the Oklahoma certification process . . . doctors must perform four proctored LVC [laser vision correction] cases within one year of completion.” The course prerequisites included completion of the Northeastern course “Laser Therapy for the Anterior Segment,” which includes nine didactic and seven clinical hours.2
It should be noted that eye patients rate ophthalmologists more highly on quality of care than they do optometrists. In October 2003, as the Oklahoma laser surgery issue was morphing into a VA issue, the Academy commissioned a survey by a company called QEV Analytics. QEV queried 1,000 veterans across the country on a variety of issues. Sixty percent of patients who had been treated by an ophthalmologist rated their treatment as excellent. Optometrists got an excellent ranking from only 40 percent of their patients. That survey also underlined the confusion in the public’s mind about the difference in training and education between the two professions. Twenty-nine percent of the veterans queried said they believed optometrists are medical doctors; another 32 percent were unsure. Only 39 percent correctly stated that optometrists are not trained as medical doctors. Last, 95 percent of the veterans said it is very important to have a medical doctor specializing in eye care do eye surgery.
The Academy, in its July radio campaign in Oklahoma, exposed the mistaken belief that optometrists are, or may be, medical doctors, and therefore as qualified as ophthalmologists to do laser surgery and noncosmetic lid surgery.
Oklahoma: A Slippery Slope
“Ophthalmologists may have some honest differences of opinion among themselves on whether optometrists should have the authority to prescribe this or that drug,” said Bob Palmer, director of State Governmental Affairs for the Academy. “But there is no question that surgical privileges are a defining issue for the profession. In final consideration, it is the patient that loses if optometric surgery laws like Oklahoma’s are left unchallenged.
1 Murphy, J. Review of Optometry 2004;141(6):6, 10.
2 “Laser Vision Correction Presented by: NSU Oklahoma College of Optometry and TLC Laser Eye Centers April 2–4, 2004.”
Three Ways to Take Action
Contribute to the Scope Fund as generously as possible by going to www.aao.org and clicking Government Affairs, then Surgical Scope Fund. From there, you can either contribute online or download a form to fax or mail with your donation.
Contact your federal and state legislators and the U.S. president—even if the issue isn’t forefront for your area right now. Send a letter to President Bush on the issue of Surgery by Surgeons. Do this from www.aao.org by clicking Government Affairs, then Action Center. To get contact information for your state and federal representatives, hit the Elected Officials tab.
Write a letter to the editor of your local newspaper. From the Action Center, hit the Media Guide tab, click your state and pull up links to all the local newspapers. Choose one, and write to the editor of your choice. Send your letter as an email or a snail mail.
Why You Must Take Action Now
Since the passage of the 1998 Oklahoma surgical statute, the optometric lobby has pushed surgical expansion proposals in legislatures across the country. In each case, ophthalmologists have united with their medical and osteopathic colleagues to educate legislators about patient risks associated with optometric surgical expansion. As a result, ophthalmology has had victories in 18 states, and optometric surgery has not expanded past the Oklahoma borders. But, as long as optometrists continue to successfully push their agenda in the Oklahoma legislature, patient care not only in Oklahoma but also in every state is at risk. This is why all ophthalmologists must join the battle.
Optometry Is a Formidable Foe for Two Major Reasons
Dollars. An overwhelming majority of optometrists donate to the American Optometric Association’s national political action committee and to their state PACs, and that money is used to help elect friends of optometry into the state and federal legislatures. By comparison, less than half of all ophthalmologists donate to their state PAC and to OphthPAC.
Numbers. In Oklahoma, for example, there are 400-plus optometrists vs. about 160 ophthalmologists. ODs have made the best of this numerical advantage, whereas many Oklahoma state senators and assembly members have no ophthalmologists as friends or foot soldiers in their campaigns.
But ophthalmologists have exacerbated that numerical deficit by sitting on the sidelines. Here are six commons arguments they give for not getting involved, and reasons why they should.
1. Optometrists give me referrals. I don’t want to jeopardize this relationship.
Take action because: If optometrists get surgical privileges, there won’t be a need for them to refer patients to ophthalmologists.
2. I have not comanaged with optometrists, so I am not at all responsible for allowing them to make incursions into ophthalmology. Let the ophthalmologists who caused the problem fix it.
Take action because: Ophthalmologists are all in this together. And in the end, it is our responsibility as physicians to make sure patients do not suffer subpar care.
3. I pay Academy membership dues. They should handle this.
Take action because: The Academy has established the Surgery by Surgeons campaign to respond to this threat. But when it gets down to the nuts and bolts of winning over state legislatures, an individual ophthalmologist’s action or inaction will make the difference.
4. Scope of practice incursions haven’t been bad in my state. This doesn’t affect me.
Take action because: If it hasn’t happened in your state this year, it will happen next year or the year after.
5. We’ve adapted to incursions into our practices over the last several decades, why not this, too?
Take action because: This time, patients are put at significant risk.
6. If patients get bad eye surgery from ODs, there will be malpractice suits and repeal of legislation. Let the market play it out.
Take action because: The market may not take care of the problem. Even if it does, patients may suffer harm in the meanwhile.
Medicine United includes H. Dunbar Hoskins Jr., MD, Academy executive vice president; Michael W. Brennan, MD, spokesman for the Veterans Eye Treatment Safety Coalition; Allan D. Jensen, MD, Academy president; Priscilla P. Arnold, MD, president of ASCRS; Herman I. Abromowitz, MD, AMA trustee; Cynthia A. Bradford, MD, Academy secretary for State Affairs; and Ann A. Warn, MD, MBA, president of the Oklahoma Academy of Ophthalmology.