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Your Academy is about to undertake something it has never previously attempted on any issue—a survey of its entire U.S. membership on an important policy issue. Your participation is vital. The purpose of this column is to introduce the survey and to frame the questions.
Patient Safety Is Paramount
For many ophthalmologists there are very few professional issues that elicit such a strong emotional reaction as our relationship with optometry. At the community level, both professions frequently work together collaboratively in service to patients. But at the state level, legislative scope of practice battles between ophthalmology and optometry have been a fact of life for both professions for over 50 years. In recent years optometric state societies have introduced 15-20 bills annually to legislatively expand their scopes of practice, and I estimate that both sides expend (in addition to thousands of hours of time taken away from practice) about $20 million to $25 million each year on lobbying and related expenses.
Most ophthalmologists believe that these battles center on a core principle—that the privilege and responsibility to provide complex medical and surgical eye care should be based on education, experience, and demonstrated competence rather than upon lobbying, donations, and legislative fiat. This is an issue of patient safety and professionalism. The Academy holds this principle dear, and we believe it is in our patients’ best interest not to compromise that principle.
Our defense of that principle, however, does not necessarily imply that the professions should be forever in conflict on all questions with regard to the best care of patients.
Many Members Work With ODs
The practice of ophthalmology and of optometry are embedded in an evolving landscape of demographic trends, delivery structures, and economics. How, for example, should ophthalmology provide appropriate access to care for a rapidly growing and aging population? Ophthalmology, like every specialty in medicine, understands that delivery of optimal patient care is a team endeavor. Over 50% of ophthalmologists work in a practice that employs optometrists. Additionally, nearly every practice avails itself of the skills of other professionals including a mix of opticians, technicians, practice executives, nurses, orthoptists, imaging specialists, and IT experts. We are more efficient and effective working collaboratively than individually. In the operating room (with an entirely different team) all operating team members are empowered to call a timeout if there is a question as to which IOL or which medication should be employed. We, and particularly the patients, are all safer because of it.
The Academy itself has evolved during this same period. What started in 1896 as an organization dedicated to the education of only practicing ophthalmologists now includes residents, fellows, and membership categories for scientists, practice executives, and nurses—and has for years. Its Annual Meeting offers courses for all of these groups, including hundreds of offerings for ophthalmologists.
In recent years, there have been some requests from ophthalmologist members for the Academy to explore options to include educational venues for optometrists—particularly those optometrists who are in ophthalmologists’ practices. These members basically have said, “I would rather have my society educate all the members of my team.” These requests have arisen at the grassroots level from both individual members of the Academy and from individual state societies. There have also been recommendations from members that the Academy consider finding a place for these optometrists in the Academy’s structure—much as exists for other members of the eye care team.
The Perspectives
There have been strong and articulate voices on both sides of these requests. Those in support note the demographic imperative to work together to meet the needs of a growing and aging population that is not matched by a similar growth in the number of ophthalmologists. They also say that there is a broad base of support for team-based education, and they note the high quality of Annual Meeting education programs. They recognize the positive relationships between individual ophthalmologists and optometrists in providing patient care and the desirability of breaking down barriers wherever possible, albeit consistent with our patient care principles (such as teaching surgical procedures only to ophthalmologists).
Those opposed note the challenges in overcoming decades of mutual scope of practice–generated animosities, the fact that the Academy is an “ophthalmology society,” that Academy training has in the past been and might in the future be legislatively misrepresented by some optometrists and risk patient harm, and that it might “blur the lines of education and perceived competency” between the two professions. Some believe that, given the differences in training, it is impossible to provide a meaningful educational interface without compromising core quality of care and patient safety principles.
And there are other considerations—both pro and con.
Why We Need a Survey
The issues have been discussed by the Academy Board of Trustees, by the Academy Council, and by state leaderships off and on for years—and intensively over the past six months. All generally agree that a) it is a highly charged and important issue, and b) no one actually knows what the 18,000+ practicing ophthalmologists in the United States truly think about it.
Accordingly, we will all find out. In early January, the Academy will conduct a first-ever survey of its entire domestic practicing membership. It is an opinion survey, not a formal vote on an issue. The survey results will be made available to all members in early 2020. And the outcome will help guide policy as the profession and patient care advance.
A couple of things are worth noting and emphasizing. First, this discussion and this survey are not linked to any proposed change in advocacy principles or in the intensity with which these principles will be defended. The Academy remains vigorously committed to scope of clinical practice defined by education, experience, and demonstrated clinical competence.
Second, there is no predetermined plan of action. The objective is to engage the profession in a careful, deliberate discussion, and then to know, for the first time, what the membership really thinks and prefers. This will then guide where we go from here. And change should be consensus-driven. In many respects, the outcome of the survey may be less important than the process itself in clarifying the core issues of concern, raising unrecognized questions, and guiding the next steps. A member wrote to me on this subject and commented that her father always noted, “It’s the debate and discussion that are important.”
There has been increasing cooperation in some arenas between optometry and ophthalmology in recent years. We have worked together on policy statements pertaining to common ground issues such as cosmetic contact lenses. We have delivered joint educational symposia on topics such as dry eye, myopia prevention, and amblyopia. We have advocated together for payment for vision rehabilitation services for those in need, for early drop refills, prohibiting scleral tattoos, and other patient protections.
Regarding the Academy and optometry, the questions now are, “Should there be next steps and, if so, what should they be?” The potential options are not binary ones. They will be nuanced. And some may be better implemented at local or state levels than at the national one. Regardless, patient needs must remain front and center. The process for meeting these needs should be determined and led by physicians—not by politicians and policy wonks.
It is possible that, based in part on the survey responses, this profession-wide reexamination will lead to no change in Academy policies and procedures. If so, it is much better that we arrive at the decision based on careful deliberation of the alternatives, rather than unwillingness to consider alternatives. Again, the process itself has great value. It is how we as medical professionals make patient care decisions—obtaining and considering all available data.
Your Opinion Is Critical
The survey questions are being formulated by an independent professional firm in conjunction with a group of colleagues randomly chosen from state leadership to help ensure that it is as free of bias as possible. The survey will be administered by an independent survey firm. It will appear in your inbox in early January with announcements in Academy Express and Washington Report Express. Please fill it out. Your opinion is critical, and by participating you have the direct opportunity to impact your Academy’s direction.
Update:
The Comments section has been disabled now that the survey is closed. Information on the results of the survey will be posted in Academy Express and Washington Report Express by mid-February.