It's not surprising that this insightful reply comes from someone who actually has a frame of reference and not a medical student or 1st year resident who is just regurgitating the same diatribe that their attending gave them last week. (I know, I know...he's a med student but he has much more of a frame of reference than just about everyone else on here)
Excellent question. There are many factors what would come to play in establishing a national optometric standard for scope of practice. Here is my attempt to outline the issues and the potential roadblocks:
1. Would ophthalmology support it? I don't think I know enough about "Organized Ophthalmology" to know the answer. But I know many ophthalmologists who would probably support it if it was a reasonable standard based upon what optometrists are trained to do. I am not going to go into details about what I think a standardized optometric scope should entail, but I think the majority of optometrists have a pretty good grasp on what their scope of practice should entail. Furthermore, I think that most ophthalmologists would find that they agree with this majority of optometrists.
Very true.
2. The "Organized Optometry" agenda is driven by a small minority of extremists who will not stop until the profession of Optometry is indistinguishable from Ophthalmology. Also, Optometry has partnered with politicians, lawyers, and lobbyists as a means to push their scope of practice agendas. It seems that Organized Optometry, in partnering with lawyers and politicians, have adopted a "shotgun" approach of pushing for privileges way beyond their training in hopes that the final outcome will be bargained down to a reasonable request. Think about how this looks from the Ophthalmology perspective: 1) Optometry has partnered with lawyers (a profession that is almost universally distrusted in the medical world), and 2) how is Ophthalmology supposed to distinguish between what Organized Optometry really thinks it ought to have versus everything else that is padded into these scope of practice bills? How does one separate the wheat from the chaff?
The reason that optometry partnered with lawyers and lobbyists was that we got absolutely zero support from ophthalmologists. We can all remember the ophthalmologists waving around the bottles of tropicamide in the state legislature hearings and ominously declaring that it could KILL people, which essentially implied that if ODs were allowed to examind the fundus, bodies would pill up all over the streets of America.
2. Organized Ophthalmology is not without fault either. Organized Ophthalmology has also been known to partner with lawyers and politicians by attempting to enact (and sometimes succeeding temporarily) legislation that puts optometry back into the stone age by taking away things that optometrists are trained to do. It then becomes a game of "Who can push harder," or "My lawyer is better than your lawyer," or "Your politician's mother is soooooooooooooooooooooooo ugly......."
This is also true and there are many examples of it. This is why I think it is important to sit down and have reasonable people from both sides come up with a reasonable plan that meets the needs of the public and the professions. At this stage of the game, it seems that both sides are so distrustful of each other that it's not likely to happen. Another issue for optometry is that we have gotten burned many times with having "formulary" type legislation and scope of practice that specifies which drugs, or which procedures can be done. We saw this in New York when Xalatan came on the market. The argument was made that since prostaglandin analogues were not included in the original bill, ODs could not use prostaglandin analogues. Then the argument was made that since ODs couldn't use the newest and most effective treatments for glaucoma, they shouldn't allowed to use any. ODs were suspended from treating patients that they had safely and effectively been treating for years. We need the ability to incorporate new technologies and treatment modalities into our treatment regimes. Unfortunately, ophthalmology always assumes that that means "do surgery" and they're basically wrong.
Optometry has essentially gone for a scope of practice that includes "everything" not because we want to "do everything" but because we are tired of having to grovel before the medical society in all 50 legislatures every time some new drug or technology comes out. On some level, I understand the concern of ophthalmology here but we need to be honest with ourselves. The overwhelming majority of ODs work in their own (usually solo) private practices or commercial locations. There just isn't the volume of surgical cases in EITHER of these practice modalities to justify the expense of lasers or the pursuit of these priviledges etc. It's economically unfeasible. I am a partner in an optometric practice that is fairly "medically oriented" in the sense that we emphasize our examinations and our treatments much more than our material sales. We have a good working relationship with local primary care docs, internal medicine people and neurologists. Even in an office the size of ours, the volume of surgical cases that we send out in a month is incredibly low. We just don't see many of "those patients" anyways. It makes no sense for us to do them.
But even as a hypothetical....let's say that we did see a high volume of surgical cases that we refer out...it STILL wouldn't make economic sense because if optometrists suddenly start doing "surgery" and even if only a small number of them do it, it has the effect of making a HUGE increase in the number of surgical providers but it keeps demand for those procedures exactly the same! Optometrists GET THIS. And this IS NOT what we want!
You think we want $660 for a cataract extraction with all the attendant crap and corruption that comes along with it? You think I want to spend thousands of dollars on a laser to do YAGs and PIs, of which I see maybe one or two a month? I could see one or two extra patients and sell one pair of glasses and make the same money WITHOUT the attendant risk and aggrivation. THis is why I keep harping over and over again that this issue IS about money, but it's NOT about money from performing these procedures.
Not only that, but optometrists tend to be OVERconservative to a fault. If anything, we OVER refer. The notion that optometrists, if granted a broad scope of practice are going to suddenly and recklessly rush out and start slicing and zapping the unsuspecting public is beyond ridiculous. Just as another person pointed out on here somewhere, you don't see ophthalmologists performing Whipples even though they are licensed to do it. It's no different with optometrists. Just because we would technically be licensed to do something doesn't mean we're all going to rush out and start doing it, or that optometry schools are going to suddenly turn into surgeon mills. It makes so little sense.
3. If both sides of the aisle would clean up their own houses by pushing their extremists aside, it would be relatively easy to spend a few years hammering out a reasonable, well-delineated scope of practice that both sides find acceptable. However, the problems outlined in #1 and #2 above have occurred over the course of many years. This mutual distrust will be the biggest obstacle, and this obstacle will not be disassembled overnight. Needless to say, I am still optimistic that the future will be better for both professions.
I agree with this wholeheartedly. A brilliant and succinct response.
Again, it's about money...but NOT money from procedures. We want to be able to adapt to new technologies and incorporate new drugs into our practices. And we want our patients back when we refer them out. I know....I know....the patients sometimes want to stay with the ophthalmologists. That's fine. And many times we're HAPPY to have the patients stay with the ophthalmologist. But please...let's not have any more of this crap where the ophthalmologist finds some "unusual astigmatism" that requires the whole family to be seen or the scenario where the ophthalmologist tells a mother that an OD recklessly treated their 14 year olds blepharitis with blephamide and how we aren't trained to use blephamide.
There's plenty of pie to go around. Let's stop this silly bickering because all it does is makes lawyers and lobbyists rich.
