Do you support Optometrists doing surgery? - ODs allowed to do scalpel surgery in OK!

[Mirror Form]

This amuses me to no end.......

Optometric Physician
Physicain and Surgeon of the Eye
Podiatric Physician
Physician and Surgeon of the Foot and Ankle

He He He.........Why even have this argument? It is never going to go anywhere....the Opthalmologist I shadow refers to his OD counterparts as Physicians.....And even if he didn't I really don't think that OD's care---as long as it is legal you can use it.....Case in point---Ohio mandates that somewhere in your signage (i.e. business card) you have to have OD somewhere......So you put Dr. So and So OD, Optometric Physician or Physician of the Eye-----both are legal as long as you have OD "somewhere." I just visited a interdiscplinary clinic in Kentucky that has 2 optos and 2 opthos working together...The sign on the door reads Dr. So and So, Dr. So and So, Dr So and So, and you guessed it----Dr. So and So....! No mention of MD or OD......This is the way it should be.......equal and mutually respectful of each other.........but I have to admit these stupid arguements are funny....

The MD, DO, OD, etc., titles aren't just about egos and respect amongst healthcare professionals. The titles are there so that patients know what kind of training the person treating them has had. Also, given everything that has been going on with OD's lobbying for surgical rights, you must realize why many MD's and DO's do not want the lines blurred b/w their degrees and OD degrees.

---

Members don't see this ad.

 

[Andrew_Doan]

I am presenting at the Academy's Mid-Year Forum this week. For those interested, here is my talk: http://webeye.ophth.uiowa.edu/eyeforum/downloads/PoliticalAdvocacy_Internet_Doan.pdf

 

[Ben Chudner]

I've read with great interest this entire thread, and I am amazed that this is the same arguement I heard over 10 years ago regarding optometric use of therapeutic pharmaceutical agents (TPA's). I think there are some very large misunderstandings on both sides of this issue.

First of all, let me explain my credentials so that I cannot be accused of not understanding the issue. I am one of the OD's that chose to do a residency in ocular disease. I completed that one-year residency at Bascom Palmer Eye Institute. For those that do not know the program, it is consistently ranked as the number 1 or 2 ophthalmology hospital in the country, so I have seen how your top guns are trained. I have also worked in OK and NM eye clinics during my clinical rotations, so I have a unique prespective on what the OD's in the trenches really want.

Let me start on the OD side. I believe that a lot of OD's do not have the proper respect for the training that OMD's go through. As I said I watched the training, attended grand rounds and FA conference with your residents and saw what they went through. The OD training is not the same as the OMD training, but until you've seen our training first hand (not through sisters, brothers, cousins) you are not in the position to accurately comment on it, just as I have no idea what your medical school training was like even though several of my immediate family have MD behind their name.

On the OMD side, your profession has continually overstated the goals of optometry. I will not deny that there is a very small renagade group that would like to see OD's doing cataract surgery. Unfortunately, they have been very vocal and your AOA has taken their comments and run with them. I assure you they are in no way the majority. There is another large group of OD's, mostly older docs that are content to stay right where we are. Then there is what I feel is a growing number of OD's that would like to expand the scope to include orals, injections and lasers. This may be the majority now, I am not sure. This group is not really looking for LASIK, or even LASEK. They would like to perform ALT's, PI's, and Yag Caps. Procedures which OD's have done successfully for several years in both OK and the VA system (until the recent ruling).

Your arguements that OD's are not qualified to perform surgery are accurate depending on the procedure. I do not think OD's can perform cataract surgery, trabs, blephs, scleral buckles, and the list goes on. As for anterior segment lasers with the exception of refractive surgery, your arguement falls a little short based on experience. As I said, OD's have been perfroming these procedures for several years, and to my knowledge there has yet to be a single malpractice case. There has never been a report of visual loss attributed to an OD performing these procedures.

Will OD's win this battle in every state? I have no idea. I do know that neither side will agree on this issue until all the misunderstandings are gone. There will always be that renagade few that want to be OMD's, and maybe that's because they wanted to get into med school and couldn't. As you can see form the posts on this site, most of us chose optometry, it did not choose us, and we knew what we would be able to do as doctors. As for me, I don't personally care about expanding our scope, except as a defese against limiting our scope which has been tried by MD's in several states, not just the most agressive ones. States where topical glaucoma meds were taken away for example (restored, of course). I am happy being the primary doc I was trained to be.

One last point to make. I know most of you are students and have not actually been in private practice. There is not a lot of money in Yags, PI's and ALT's. For example, the reimbursement on a Yag Cap is about $128 dollars in my state. There are no facility fees for a Yag that is kept in the office, so to make anymore you have to keep it in an ASC. The reason OK has so many OD's doing the procedure is because places like TLC allow OD's to bring their patients in to use the TLC lasers

Ben Chudner, OD, FAAO

 

[futuredoctorOD]

The MD, DO, OD, etc., titles aren't just about egos and respect amongst healthcare professionals. The titles are there so that patients know what kind of training the person treating them has had. Also, given everything that has been going on with OD's lobbying for surgical rights, you must realize why many MD's and DO's do not want the lines blurred b/w their degrees and OD degrees.

I understand your point......

 

[EYESURG]

It's not blurring that much yet.

It's easy for optometry to ask for more and always step back and ask for less, such as "minor procedures". However, the laws in OK and NM aren't asking for just what you describe above. Until optometry steps back, I will continue to post, be involved politically with the AAO, and give money to my PAC. BTW, my efforts are paying off because I have worked with several AAO leaders to register over 35 residents for the Mid-Year Forum in Washington D.C. in April (http://www.eyeorbit.org/article.php?story=20050125235057335). This is almost a three-fold increase in resident participation from last year. I'll be attending this year as a guest speaker. Thanks for your comments, but apathy is not in my vocabulary.

This is the best post in a while....You go Andrew. No apathy.

 

[EYESURG]

I've read with great interest this entire thread, and I am amazed that this is the same arguement I heard over 10 years ago regarding optometric use of therapeutic pharmaceutical agents (TPA's). I think there are some very large misunderstandings on both sides of this issue.

First of all, let me explain my credentials so that I cannot be accused of not understanding the issue. I am one of the OD's that chose to do a residency in ocular disease. I completed that one-year residency at Bascom Palmer Eye Institute. For those that do not know the program, it is consistently ranked as the number 1 or 2 ophthalmology hospital in the country, so I have seen how your top guns are trained. I have also worked in OK and NM eye clinics during my clinical rotations, so I have a unique prespective on what the OD's in the trenches really want.

Let me start on the OD side. I believe that a lot of OD's do not have the proper respect for the training that OMD's go through. As I said I watched the training, attended grand rounds and FA conference with your residents and saw what they went through. The OD training is not the same as the OMD training, but until you've seen our training first hand (not through sisters, brothers, cousins) you are not in the position to accurately comment on it, just as I have no idea what your medical school training was like even though several of my immediate family have MD behind their name.

On the OMD side, your profession has continually overstated the goals of optometry. I will not deny that there is a very small renagade group that would like to see OD's doing cataract surgery. Unfortunately, they have been very vocal and your AOA has taken their comments and run with them. I assure you they are in no way the majority. There is another large group of OD's, mostly older docs that are content to stay right where we are. Then there is what I feel is a growing number of OD's that would like to expand the scope to include orals, injections and lasers. This may be the majority now, I am not sure. This group is not really looking for LASIK, or even LASEK. They would like to perform ALT's, PI's, and Yag Caps. Procedures which OD's have done successfully for several years in both OK and the VA system (until the recent ruling).

Your arguements that OD's are not qualified to perform surgery are accurate depending on the procedure. I do not think OD's can perform cataract surgery, trabs, blephs, scleral buckles, and the list goes on. As for anterior segment lasers with the exception of refractive surgery, your arguement falls a little short based on experience. As I said, OD's have been perfroming these procedures for several years, and to my knowledge there has yet to be a single malpractice case. There has never been a report of visual loss attributed to an OD performing these procedures.

Will OD's win this battle in every state? I have no idea. I do know that neither side will agree on this issue until all the misunderstandings are gone. There will always be that renagade few that want to be OMD's, and maybe that's because they wanted to get into med school and couldn't. As you can see form the posts on this site, most of us chose optometry, it did not choose us, and we knew what we would be able to do as doctors. As for me, I don't personally care about expanding our scope, except as a defese against limiting our scope which has been tried by MD's in several states, not just the most agressive ones. States where topical glaucoma meds were taken away for example (restored, of course). I am happy being the primary doc I was trained to be.

One last point to make. I know most of you are students and have not actually been in private practice. There is not a lot of money in Yags, PI's and ALT's. For example, the reimbursement on a Yag Cap is about $128 dollars in my state. There are no facility fees for a Yag that is kept in the office, so to make anymore you have to keep it in an ASC. The reason OK has so many OD's doing the procedure is because places like TLC allow OD's to bring their patients in to use the TLC lasers

Ben Chudner, OD, FAAO

Very good post; however, it usually starts with minor things and then moves on to major things like phaco...etc. Also, you have to draw the line at some point and that in my openion is surgery whether Yags or whatever. If you don't draw the line then where do you stop?

 

[Ben Chudner]

Very good post; however, it usually starts with minor things and then moves on to major things like phaco...etc. Also, you have to draw the line at some point and that in my openion is surgery whether Yags or whatever. If you don't draw the line then where do you stop?

I guess that is the fundamental question. Where do you stop? I know that there are those in my profession that will not stop at anterior seg lasers, just as there are those in your profession that will continue to try and take away from our current scope. I wish it would be as simple as having the leaders of each of the AOA's sit down and decide "this is the line", but we all know neither side will agree on where that line is. Just as you feel surgery is that line, and I see that OD's have proven successful at some anterior seg lasers.

 

[Andrew_Doan]

Just as you feel surgery is that line, and I see that OD's have proven successful at some anterior seg lasers.

Please show me the data to support your point that "OD's have proven successful at some anterior seg lasers". Also, lack of malpractice claims is not a good assessment of success.

One last point. I think OD's need to see enough pathology in order to make the call for some anterior seg lasers, such as PIs.

An OD sent us a patient for a LPI without angle closure. We diagnosed chronic glaucoma from pseudoexfoliation syndrome (http://webeye.ophth.uiowa.edu/eyeforum/case8.htm). There is more to doing surgery than simply knowing how to go through the motions. The decision making process to determining when to do surgery requires medical school, residency, and experience with pathology.

While all this contemplation about optometric surgery is interesting, we must all ask if society will benefit from an alternative route to ophthalmic surgery? Do we need more ophthalmic surgeons? Why do we need more ophthalmic surgeons?

 

[JennyW]

Please show me the data to support your point that "OD's have proven successful at some anterior seg lasers". Also, lack of malpractice claims is not a good assessment of success.

One last point. I think OD's need to see enough pathology in order to make the call for some anterior seg lasers, such as PIs.

An OD sent us a patient for a LPI without angle closure. We diagnosed chronic glaucoma from pseudoexfoliation syndrome (http://webeye.ophth.uiowa.edu/eyeforum/case8.htm). There is more to doing surgery than simply knowing how to go through the motions. The decision making process to determining when to do surgery requires medical school, residency, and experience with pathology.

While all this contemplation about optometric surgery is interesting, we must all ask if society will benefit from an alternative route to ophthalmic surgery? Do we need more ophthalmic surgeons? Why do we need more ophthalmic surgeons?

I would say that a lack of malpractice cases is a very good assessment of success. I am sure that if an OD had botched an anterior seg laser that caused complications and an OMD had to fix or that resulted in a lawsuit, it would be trumpted from the AAO in all of its publications in the largest type possible.

In defense of the OD in this case, it's possible that he did not examine the patient. He might have seen the 71 and made the (wrong) assumption that it was an angle closure and immediately sent it out. In the VA, I have seen optometry students AND ophthalmology residents make this same mistake.

But I do agree with you that there is no need for more eye surgeons. I also think it is not economically viable for ODs to have lasers in their offices. There is just no way that ODs, or even a group of ODs would be able to generate the volume of patients.

Virtually every OD realizes this. And that is why I am starting to think that the battle for "surgical rights" is not about PIs, or YAGs, or LASIK, but about who is going to ultimately control the profession of optometry, optometrists or MDs.

Jenny

 

[Andrew_Doan]

I would say that a lack of malpractice cases is a very good assessment of success. I am sure that if an OD had botched an anterior seg laser that caused complications and an OMD had to fix or that resulted in a lawsuit, it would be trumpted from the AAO in all of its publications in the largest type possible.

ODs have the privilege of claiming that it's beyond their scope of practice and they are not the specialist. Blame is often placed on the treating MDs instead. Furthermore, given that ODs do not do many procedures, there cannot be many malpractice cases generated from the low volume of procedures. Malpractice cases, therefore, is a POOR outcome measure for ODs' success, particularly when there are low volume of cases. If I had only done 30 cataracts surgeries in my lifetime, then I can claim 100% success without vitreous loss. However, if you do enough surgery, then you'll encounter problems. Trust me. My rate of vitreous loss is not zero.

Thus, without data to show me clinical outcomes. Malpractice claims are bad measures of competence.

In defense of the OD in this case, it's possible that he did not examine the patient. He might have seen the 71 and made the (wrong) assumption that it was an angle closure and immediately sent it out. In the VA, I have seen optometry students AND ophthalmology residents make this same mistake.

In response to your comment about the treating OD, asking one question would have ruled-out acute angle closure... "do you have pain?" Also, your argument of not seeing the patient doesn't hold here; and, why are you comparing a licensed optometrist to optometry students and ophthalmology residents? As a referring doctor or optometric physician, optometrists should evaluate the patient. We treated the patients with drops, which could have been done by the optometrist.

 

[brendang]

ODs have the privilege of claiming that it's beyond their scope of practice and they are not the specialist. Blame is often placed on the treating MDs instead. Furthermore, given that ODs do not do many procedures, there cannot be many malpractice cases generated from the low volume of procedures. Malpractice cases, therefore, is a POOR outcome measure for ODs' success, particularly when there are low volume of cases. If I had only done 30 cataracts surgeries in my lifetime, then I can claim 100% success without vitreous loss. However, if you do enough surgery, then you'll encounter problems. Trust me. My rate of vitreous loss is not zero.

Thus, without data to show me clinical outcomes. Malpractice claims are bad measures of competence.



In response to your comment about the treating OD, asking one question would have ruled-out acute angle closure... "do you have pain?" Also, your argument of not seeing the patient doesn't hold here; and, why are you comparing a licensed optometrist to optometry students and ophthalmology residents? As a referring doctor or optometric physician, optometrists should evaluate the patient. We treated the patients with drops, which could have been done by the optometrist.

And this will NEVER change... Well said, Andrew. Excellent post.

 

[Ben Chudner]

And this will NEVER change... Well said, Andrew. Excellent post.

I don't wish to be adversarial, but lasers have been within the scope of practice for Oklahoma OD's for the better part of 20 years (minus a few years when the law was challenged). There is no way they can avoid a malpractice claim for performing a laser procedure. Furthermore, any OD that performed a laser procedure that was outside their scope of practice, would not only have no protection in a lawsuit, ie they couldn't claim that they are not liable because it is beyond their scope, they would have been practicing medicine without a license which is, I believe, a criminal offense.

That being said, I agree that the best way to prove my point is with numbers which I am in the process of getting, but be honest. If I find out that there have been over 10,000 procedures in the last 20 years, with no reported complications, would that really change your mind?

 

[Andrew_Doan]

I don't wish to be adversarial, but lasers have been within the scope of practice for Oklahoma OD's for the better part of 20 years (minus a few years when the law was challenged).

So when was scalpel surgery part of Oklahoma OD's scope of practice? I ask because this current ruling in OK allows you to do pterygium excision and removal of lid lesions. You and I know that Oklahoma is shooting for more than yag capsulotomies... Please stop clouding the surgical issues by asking for more and stepping back to accept less.

I also doubt there are clinical outcome numbers because there are none published in the literature. Ophthalmologists publish clinical outcome data all the time. Why don't optometrists publish them too? I wasn't aware that Oklahoma OD's were allowed to do lasers before the 1998 law.

http://www.crstoday.com/PDF Articles/1004/Brennan.html

www.crstoday.com][/url]
OPTOMETRIC SURGERY IN OKLAHOMA
(November 1998)

In stark contrast to the VA scene where the optometric strike was silent, sudden, and almost subtle, the Oklahoma encounter lasted a decade and featured legislative and legal face-offs. Optometrists who had attended a laser surgery session at the annual AAO meeting began performing PRK and YAG capsulotomies at the Northeastern State University College of Optometry (Tahlequah, OK) in the mid-1990s, based on the assumption that a clause in the scope-of-practice statute permitted optometric laser surgery. Years later, the Optometric Board of Examiners finally “certified” optometrists to perform anterior segment laser surgery. Legislative attempts to either sanction or disallow optometric laser surgery led to several legal encounters between the Oklahoma Board of Licensure (Medical Board) and the Oklahoma Board of Examiners in Optometry. In July 1997, the court issued a ruling prohibiting optometric laser surgery. Optometry redirected its efforts to political persuasion, and Senate Bill 11-92 was enacted, permitting laser surgery excluding retinal laser, LASIK, and cosmetic lid surgery. Noteworthy was the optometric campaign slogan, “if it’s good enough for veterans, it’s good enough for Oklahomans,” which referred to the VA Optometry Service Guide mentioned earlier. In Oklahoma, relatively few optometrists were performing laser procedures and these in small numbers. Out-of-state optometrists, including several VA practitioners, became licensed in Oklahoma via weekend courses and board examinations. Included in the Northeastern State University College of Optometry’s advertisements were weekend courses for other opportunities, such as Botox injection (Allergan, Inc., Irvine, CA), advanced suturing, and excision of lid lesions.

 

[Ben Chudner]

So when was scalpel surgery part of Oklahoma OD's scope of practice? I ask because this current ruling in OK allows you to do pterygium excision and removal of lid lesions. You and I know that Oklahoma is shooting for more than yag capsulotomies... Please stop clouding the surgical issues by asking for more and stepping back to accept less.

I also doubt there are clinical outcome numbers because there are none published in the literature. Ophthalmologists publish clinical outcome data all the time. Why don't optometrists publish them too? I wasn't aware that Oklahoma OD's were allowed to do lasers before the 1998 law.

http://www.crstoday.com/PDF Articles/1004/Brennan.html

"Dr. Eldridge dates the story back to 1987 when Oklahoma optometrists took advantage first of YAG lasers coming on the market, then argon lasers as tools for capsulectomies and other procedures. They also took advantage of the fact that there was nothing in state law that said they couldn't perform these procedures themselves."

http://www.aao.org/aao/news/eyenet/archive/05_99/tlc_feature.html

Dr. Eldridge was one of the first OD's in OK to purchase a laser. The 1998 law only re-established OD's right to perform laser surgery. Before 1997, there was no wording prohibiting lasers by OD's in the OK law. In 1997, OMD's successfully blocked OD's using lasers, until the law was changed in 1998. So we are talking about 18 years, or the better part of 20, whichever wording you prefer.

 

[Andrew_Doan]

In the editorial appearing in the April 1 edition of the The Oklahoman, Dr. Warn, president of the Oklahoma Academy of Ophthalmology, obliterates the OD’s argument that a new rule allowing optometrists to perform surgery with a scalpel is for the good of Oklahoma patients. To the OD position that patients shouldn’t have to travel several hours to an ophthalmologist’s office when the optometrist’s office is just down the street, Warn offers this: 99 percent of Oklahoma's citizens live within 60 miles of an ophthalmologist's office. Should “podiatrists should do hip surgery because there is no orthopedic surgeon within an hour's drive of the patient?” she asks. Dr. Warn’s editorial is part of ophthalmology’s effort to convince Oklahoma’s legislature to reject the new OD scalpel surgery rule the governor signed last month. Working with the Oklahoma Academy of Ophthalmology, the Oklahoma Osteopathic Association and the Oklahoma State Medical Association, we have developed a strong political campaign designed to move Oklahoma residents and ophthalmologists to contact their state legislators.

You too can make a difference! Contribute to the Surgical Scope Fund today.
_______________________________

The above was published the AAO Washington Report Express.

 

[Loncifer]

In the editorial appearing in the April 1 edition of the The Oklahoman, Dr. Warn, president of the Oklahoma Academy of Ophthalmology, obliterates the OD’s argument that a new rule allowing optometrists to perform surgery with a scalpel is for the good of Oklahoma patients. To the OD position that patients shouldn’t have to travel several hours to an ophthalmologist’s office when the optometrist’s office is just down the street, Warn offers this: 99 percent of Oklahoma's citizens live within 60 miles of an ophthalmologist's office. Should “podiatrists should do hip surgery because there is no orthopedic surgeon within an hour's drive of the patient?” she asks. Dr. Warn’s editorial is part of ophthalmology’s effort to convince Oklahoma’s legislature to reject the new OD scalpel surgery rule the governor signed last month. Working with the Oklahoma Academy of Ophthalmology, the Oklahoma Osteopathic Association and the Oklahoma State Medical Association, we have developed a strong political campaign designed to move Oklahoma residents and ophthalmologists to contact their state legislators.

You too can make a difference! Contribute to the Surgical Scope Fund today.
_______________________________

The above was published the AAO Washington Report Express.

Dr. Doan,
I have 2 questions regarding your post and I ask both with a genuine respect for you and a desire to better understand the situation in Oklahoma.
1)With this new rule allowing scalpel surgery to be performed in OK, have any ODs performed such procedures? If so, what were they (hordeolum excision, open glode surgery)?
2)My understanding of the OK situation is that the legislative language used is to protect the scope of OD practice vis-a-vis FB removal, epilation, curettage etc. and that the primary concern from Ophthalmology is the use by ODs of anterior segment lasers. Is this accurate?
Thank you in advance of your reply.

 

[Andrew_Doan]

1)With this new rule allowing scalpel surgery to be performed in OK, have any ODs performed such procedures? If so, what were they (hordeolum excision, open glode surgery)?
2)My understanding of the OK situation is that the legislative language used is to protect the scope of OD practice vis-a-vis FB removal, epilation, curettage etc. and that the primary concern from Ophthalmology is the use by ODs of anterior segment lasers. Is this accurate?
Thank you in advance of your reply.

I know of ODs in Oklahoma who have assisted in pterygium excisions. I am not sure of the surgeries that have been performed to date.

The language is for scope expansion, NOT protection of current scope. Remember, ODs in Oklahoma have been doing refractive surgery: anterior segment lasers, PRK and LASEK since 1998 (at the minimum). The legislative language serves the purpose of scope expansion in scalpel surgery.

 

[Loncifer]

I know of ODs in Oklahoma who have assisted in pterygium excisions. I am not sure of the surgeries that have been performed to date.

The language is for scope expansion, NOT protection of current scope. Remember, ODs in Oklahoma have been doing refractive surgery: anterior segment lasers, PRK and LASEK since 1998 (at the minimum). The legislative language serves the purpose of scope expansion in scalpel surgery.

Dr. Doan,

Thank you for your reply, I find the propaganda of both sides difficult to sift through. For example, the Oklahoma's association offers this from October, 2004:
"Governor Brad Henry has signed the new Rules established by the Oklahoma Board of Examiners in Optometry confirming the existing scope of practice and more narrowly defining the surgical procedures optometric physicians may perform."
Meanwhile, the AAO states:
"The bill authorizes the Board of Examiners in Optometry—a body composed mainly of optometrists—to decide optometric scope of practice including the types of surgeries optometrists will be able to perform on the eye and face, including cataract surgery, plastic surgery, facial reconstruction and eyeball removal."

Clearly, there is misuderstandand or misrepresentation from one or both sides. The more I examine this issue the more I realize how naive I am about the politics of health care. I really hope that when I enter practice some of these issues are resolved; further to that, I hope that the relationship I enjoy with MD's is more productive than what I currently expect.

 

[optometrist]

This whole war between ophthalmology and optometry is silly and is only motivated by money. It's a turf war with ophthalmologists saying optometrists aren't "smart enough" or capable of managing ocular disease. I have read the same books as an ophthalmologist and use the same instruments as an ophthalmologist during an eye exam. I have worked for an ophthalmologist for several months and can't tell you the number of patients i've seen diagnosed with glaucoma who have a 0.2 cup/disc ratio and haven't even have a visual field done. They were diagnosed off of a technician's IOP reading, with a subsequent OCT scan showing questionably decreased RFNL. You call this good patient care?

I personally worked up a patient with a history of unexplained decreased vision in one eye. The exam seemed unremarkable and the patient was sent to a retina specialist for a fluorescein angiogram. This also came back unremarkable. So this patients decreased vision was just left undiagnosed but tons of testing was being done (OCT, visual fields, fluorescein angiograms, etc). When i saw the patient, i saw three diopters of astigmatism during retinoscopy in the eye with the poor vision. This patient had never seen well in that eye and simply had amblyopia.

Anytime i see an ophthalmologist question the skills of an optometrist, i question that doctor's motives as well as their own self esteem.

 

[JennyW]

This whole war between ophthalmology and optometry is silly and is only motivated by money. It's a turf war with ophthalmologists saying optometrists aren't "smart enough" or capable of managing ocular disease. I have read the same books as an ophthalmologist and use the same instruments as an ophthalmologist during an eye exam. I have worked for an ophthalmologist for several months and can't tell you the number of patients i've seen diagnosed with glaucoma who have a 0.2 cup/disc ratio and haven't even have a visual field done. They were diagnosed off of a technician's IOP reading, with a subsequent OCT scan showing questionably decreased RFNL. You call this good patient care?

I personally worked up a patient with a history of unexplained decreased vision in one eye. The exam seemed unremarkable and the patient was sent to a retina specialist for a fluorescein angiogram. This also came back unremarkable. So this patients decreased vision was just left undiagnosed but tons of testing was being done (OCT, visual fields, fluorescein angiograms, etc). When i saw the patient, i saw three diopters of astigmatism during retinoscopy in the eye with the poor vision. This patient had never seen well in that eye and simply had amblyopia.

Anytime i see an ophthalmologist question the skills of an optometrist, i question that doctor's motives as well as their own self esteem.

Oh boy.

And here we go again.....just when there was a faint glimmer of hope.

 

[rubensan]

Welcome to the forum!

I personally worked up a patient with a history of unexplained decreased vision in one eye. The exam seemed unremarkable and the patient was sent to a retina specialist for a fluorescein angiogram. This also came back unremarkable. So this patients decreased vision was just left undiagnosed but tons of testing was being done (OCT, visual fields, fluorescein angiograms, etc). When i saw the patient, i saw three diopters of astigmatism during retinoscopy in the eye with the poor vision. This patient had never seen well in that eye and simply had amblyopia.

Good for you! It sounds like your patients are lucky to have you!
A lot of us on this forum are trying this new thing where we try not to base the strengths/weaknesses of ODs vs. OMDs on anecdotal evidence. For every case of OMDs misdiagnosing something that you bring to this forum, there are many OMDs that can provide cases for OD mismanagement. It's a viscious cycle as many threads will illustrate.

Perhaps your energies could be put to more constructive use by giving us your opinions on the following thread: http://forums.studentdoctor.net/showthread.php?t=197548

Warm Regards,
Ruben

 

[rubensan]

Oh boy.

And here we go again.....just when there was a faint glimmer of hope.

oh, there's still hope!

 

[Tony.]

oh, there's still hope!

 

[smiegal]

Welcome to the forum!
Good for you! It sounds like your patients are lucky to have you!
A lot of us on this forum are trying this new thing where we try not to base the strengths/weaknesses of ODs vs. OMDs on anecdotal evidence. For every case of OMDs misdiagnosing something that you bring to this forum, there are many OMDs that can provide cases for OD mismanagement. It's a viscious cycle as many threads will illustrate.

Perhaps your energies could be put to more constructive use by giving us your opinions on the following thread: http://forums.studentdoctor.net/showthread.php?t=197548

Warm Regards,
Ruben

 

[ODhopeful]

I'd say everyone just be nice to each other and don't let money get in between the two professions. We need each other to perform our duties correctly and effectively. I think optometrist and OMDs should have a big hug with each other and make up for the differences throughout the years.

 

[ODhopeful]

Anyone wanna be friends????

 

[Andrew_Doan]

I'd say everyone just be nice to each other and don't let money get in between the two professions. We need each other to perform our duties correctly and effectively. I think optometrist and OMDs should have a big hug with each other and make up for the differences throughout the years.

I agree. We need to work together. Let's draw the line at surgery defined by leaders from both sides who can think outside the box. I am not talking about epilations and FB removal. We all know what surgeries I am talking about so please don't reply and argue about FB removal. In return for backing down from surgery, ophthalmologists will share their knowledge to strengthen optometrists' primary care skills.

I promise to help unite the fields, but we will need to do this as a team. Any young leaders with vision browsing SDN? Any leaders who are ready to take action rather than be passive thinkers?

 

[Tony.]

I think optometrist and OMDs should have a big hug with each other and make up for the differences throughout the years.

i wish it was that simple

 

[Tony.]

I promise to help unite the fields, but we will need to do this as a team. Any young leaders with vision browsing SDN? Any leaders who are ready to take action rather than be passive thinkers?

dr. doan,
spell out what 'action' you want a 'young leader' to take....(so we all know)

 

[Andrew_Doan]

dr. doan,
spell out what 'action' you want a 'young leader' to take....(so we all know)

Graduate from optometry school and then be a leader. Work your way up in your OD leadership, and I work my way up in ophthalmology leadership. We find other leaders who think the same and implement change and compromise. It's not easy. It's hard. But this is the kind of action I am talking about.

As an OD, speak up against surgical expansion. I am speaking up here and in the AAO. I also advocate to stop glasses dispensing amongst ophthalmologist. These are the types of action I am talking about. Stop talking about it, and do something about it.

I've been to Capital Hill twice and will continue to go in the future. Get involved and learn all you can about the issues. Don't be reactive, be creative.

 

[VA Hopeful Dr]

I think this idea of our generation of MDs and ODs establishing a better relationship is great, I'm all for it. But I forsee one big problem we might run in to. MDs want ODs to not do surgery; ODs tend to want expanded Rx rights (in most states, at least), equal reimbursement, co-management, and the optical shop idea probably isn't a bad one either. Are MDs willing to work on all those things in exchange for ODs not doing surgery?

 

[Andrew_Doan]

I think this idea of our generation of MDs and ODs establishing a better relationship is great, I'm all for it. But I forsee one big problem we might run in to. MDs want ODs to not do surgery; ODs tend to want expanded Rx rights (in most states, at least), equal reimbursement, co-management, and the optical shop idea probably isn't a bad one either. Are MDs willing to work on all those things in exchange for ODs not doing surgery?

I am.

Standard Rx Rights in all states, with all drops but limited oral medications.
No Surgery for ODs.
Discourage optical shops for MDs, unless they work with OD.
Equal reimbursement.
ODs can see all my post-ops at 1 month out.

 

[VA Hopeful Dr]

I am.

Standard Rx Rights in all states, with all drops but limited oral medications.
No Surgery for ODs.
Discourage optical shops for MDs, unless they work with OD.
Equal reimbursement.
ODs can see all my post-ops at 1 month out.

Why 1 month? With a good phaco being as clean as it is, why not see at 1 day and if everything looks clear just send them on to the OD? I know everyone does this co-manage stuff differently, so I'm basically just asking your opinion.
Also, what limitations would you place on OD oral rights?

 

[I Surgeon]

I think this idea of our generation of MDs and ODs establishing a better relationship is great, I'm all for it. But I forsee one big problem we might run in to. MDs want ODs to not do surgery; ODs tend to want expanded Rx rights (in most states, at least), equal reimbursement, co-management, and the optical shop idea probably isn't a bad one either. Are MDs willing to work on all those things in exchange for ODs not doing surgery?

Beggars can't be choosers. Be happy with what you get.

 

[Ben Chudner]

Beggars can't be choosers. Be happy with what you get.

Since I can see them at one week from the local co-management center I guess I'll send my patients to them. Since we see the majority of patients in this country I am sure the rest of the OMD's will come around if they want referrals. After all, beggars can't be choosers

 

[mdkurt]

Since I can see them at one week from the local co-management center I guess I'll send my patients to them. Since we see the majority of patients in this country I am sure the rest of the OMD's will come around if they want referrals. After all, beggars can't be choosers

Hey, Ben, it sounds like you have a nice kickback system going there. Blackmailing ophthalmologists for comanagement fees isn't actually legal, you know. Thanks for using your real name on this forum.

 

[Ben Chudner]

Hey, Ben, it sounds like you have a nice kickback system going there. Blackmailing ophthalmologists for comanagement fees isn't actually legal, you know. Thanks for using your real name on this forum.

That's really funny. I think you may be misinformed about what constitutes blackmail. I choose to use a particluar credit card over another because it gives me mileage, does that mean I am blackmailing credit card companies for free flights?

 

[Mirror Form]

That's really funny. I think you may be misinformed about what constitutes blackmail. I choose to use a particluar credit card over another because it gives me mileage, does that mean I am blackmailing credit card companies for free flights?

That's a pretty bad analogy. We're dealing with patient care here, so it's illegal to refer to certain physicians just b/c they hook you up with extra fees. That said, there is pretty much no way to prevent you from doing that, and many many other healthcare providers do the same thing (unethically) every single day.

 

[Mirror Form]

Beggars can't be choosers. Be happy with what you get.

Weren't we trying to be civil? Ya know, the whole "work together" theme?

 

[mdkurt]

That's really funny. I think you may be misinformed about what constitutes blackmail. I choose to use a particluar credit card over another because it gives me mileage, does that mean I am blackmailing credit card companies for free flights?

Well, you might be misinformed about what constitutes comanagement. The term "comanagement center" (that's a new one to me) smacks of pre-arranged agreement. Illegal. Don't take my word for it. I'm sure the government can figure out if Ben Chudner in Washington State is defrauding patients.

 

[smiegal]

If I'm not mistaken, MD billing for phacos includes post-op follow-up for 90 days, right? Do "co-managing" optometrists bill for their visits in addition to this fee, or do they receive a portion of the MD's billing for the procedure? Do the MDs stop seeing the patient after the first week?

What is the supposed advantage to a patient who is "co-managed"?

 

[VA Hopeful Dr]

A co-management center is a particular MD (or group of MDs) where the ODs refer patients that need surgery, the MD does the surgery, and the ODs do post op care and often the pre-op work as well (at least that's my understanding of it).

Co-management started because ODs were tired of sending patients to get surgery (cataract in particular) and the MD would just keep that patient for all routine care after the post-op period. As Jenny and Ben both have pointed out, its not about the money. Post-op care for cat sx pays about $120 for 90 days worth of treatment (let's say 3 visits on the low side, 5 on the high side). That's either $40 per visit or $24 per visit... co-managing certainly isn't about the money.

MDs can bill for "surgical services only" while ODs can bill for "post-operative care" under medicare. Not many other insurances do this, however. Post-op care is 20% of the total billing. So if medicare allows $600 for one cataract sx, the 90 days of post op will give the OD $120 while the MD keeps $580.

As to the blackmail, c'mon that's just ridiculous. If two drugs work almost identically with very similar results (say Travatan and Xalatan) and the Alcon rep is very generous with the samples, are you going to Rx more of his product or the one with fewer samples? Is that blackmail? Its simple economics, assuming equally competant surgeons, you refer to the ones that will send your patients back to you after they have had surgery. As a general ophthalmologist, would you refer to a retina specialist that also did cataract surgery and YAGs on the patient you sent to him?

 

[I Surgeon]

Weren't we trying to be civil? Ya know, the whole "work together" theme?

The comment was'nt that bad, was it?

 

[Ben Chudner]

Well, you might be misinformed about what constitutes comanagement. The term "comanagement center" (that's a new one to me) smacks of pre-arranged agreement. Illegal. Don't take my word for it. I'm sure the government can figure out if Ben Chudner in Washington State is defrauding patients.

Once again very funny. Let me start by saying I find people who use aliases on forums to attack others to be cowards. What are you afraid of Kurt? As for any illegality, let me elighten you. An illegal co-management situation would be one in which a kick back (money or some other incentive) is given to the referral doctor for the referral. Another illegal situation would exist if there are specific protocols written such as all patients are to be returned to the referral doctor at day one, week one, one month, etc. An example of a co-management center is TLC or PCLI in the north west. These are centers that usually perform no primary care and routinely co-manage cataract surgery and LASIK (among other things) with outside referring doctors.

In the real world (I assume you are either still in med school or are an ophthalmology resident) OD's refer to these centers for cataract surgery. We choose these centers for many reasons, such as their support of optometry as well as the knowledge that they will send the patients back to us when they feel it is appropriate. The majority of the time, that seems to be 7 to 10 days after surgery, however that changes on a per patients basis depending on what is seen at the one day visit (get it, no pre-arrangement). For the service of seeing these patients we get roughly 20% of the surgical fee from the insurance company and no more (get it, no kick back). As it turns out, the surgeons at these centers operate more than once a week and have performed thousands of surgeries and have some of the best outcomes I have ever seen (get it, we can take comfort in the knowledge that they are great surgeons and they ensure great patient care).

If you really want to talk about ethics, let's not forget it was the OMD's that used to pay OD's for cataract referrals, it was the OMD's that used to have a second surgeon simply watching in the OR during cataract surgery so that the second guy could charge an assistant fee (I wonder why Medicare doesn't allow that anymore), and it is OMD's that continue to advertise LASIK at $299 per eye and then upcharge based on Rx or using the latest technology (bait and switch, my friend). Every profession has its questionable policies, but don't try to attack the way I treat and refer my patients when I send them to the best surgeons in the area, that also happen to respect my abilities to follow those patients during the post-op period.

 

[smiegal]

Co-management started because ODs were tired of sending patients to get surgery (cataract in particular) and the MD would just keep that patient for all routine care after the post-op period. As Jenny and Ben both have pointed out, its not about the money. Post-op care for cat sx pays about $120 for 90 days worth of treatment (let's say 3 visits on the low side, 5 on the high side). That's either $40 per visit or $24 per visit... co-managing certainly isn't about the money.

Is co-management 7-10 days s/p phaco really just a logical solution to the problem of not getting patients back for routine future care? If there's an agreement to get your patients back at 7-10 days, why not just have an agreement to get them back at 90 days? An argument for patient-benefit can't really be made, either, because a patient staying longer with the MD would not receive inferior care. I'm not necessarily arguing against co-management, but at least in my eyes, a great non-self-interest argument ($) for 7-10 days vs. 90 days. has yet to be posted.


Clearly, nobody would want to lose a patient for care they are fully-capable of providing (the cataract-extracting retina surgeon is a good example - I have heard several Retina specialists say they don't do phaco's because they'd get fewer referrals). Maybe 90 days is a bit long for phaco's to be considered true post-op care....I don't know, that would be a more interesting discussion.

Dr. Chudner,
I came across your name on this link while searching for the co-management center (I'm really not stalking you):
http://cosmetic-surgery.eguidepro.com/wa_others_cosmetic_plastic_surgery.html

Do you co-manage plastics/cosmetics cases, as well? What about retina cases?

 

[Tom_Stickel]

Is co-management 7-10 days s/p phaco really just a logical solution to the problem of not getting patients back for routine future care? If there's an agreement to get your patients back at 7-10 days, why not just have an agreement to get them back at 90 days? An argument for patient-benefit can't really be made, either, because a patient staying longer with the MD would not receive inferior care. I'm not necessarily arguing against co-management, but at least in my eyes, a great non-self-interest argument ($) for 7-10 days vs. 90 days. has yet to be posted.

The main non-self interest argument, and one that has come up judicially and legislatively, is patient choice. If a patient has confidence in the referring OD and has a long and happy relationship with him, they can choose to do their routine follow-up care with him or her. It may also be that these elderly patients live much closer to the referring OD than they do the surgery center and/or OMDs office, and prefer to minimize their driving time, or distance their sons/daughters have to drive them.

Also, in selected rural areas, patients may go to the big city for surgery, which could be a drive of several hours. It's a great patient inconvenience to have to do that multiple times. Heck, even the AAO sees that as a reason for co-management.

In an effort to be 'fair and balanced', the one thing no one has mentioned is that ODs want to sell glasses. If the OMD sees the patient for 90 days, sooner or later they're going to hand over an Rx, because anisometropic patients get grumpy. ODs in general prefer to get the patient back before any Rx is written so they can write the Rx themselves. This is NOT the only reason behind the OD co-management, but it's naive to assume it's not a factor.

This is another place where Dr. Doan's suggestion for OMDs to limit dispensing would help everyone get along and play nice.

Tom Stickel, OD

 

[Ben Chudner]

Dr. Chudner,
I came across your name on this link while searching for the co-management center (I'm really not stalking you):
http://cosmetic-surgery.eguidepro.com/wa_others_cosmetic_plastic_surgery.html

Do you co-manage plastics/cosmetics cases, as well? What about retina cases?

It is scary what comes up on the internet. That is a listing from when I worked for an ophthalmology group 4 years ago. I have no idea why it comes up still, other than I guess they have never bothered to update it. In reality, that was the group putting all of their providers on every possible list to get more patients. I had no idea I was on it until you found it. I do not co-manage plastics or retina cases. I see those patients once the surgeon has released them back into my care, which in the case of retina could be several months to over a year depneding on the case.

If you want to see the co-management center's website try www.pcli.com

 

[mdkurt]

The main non-self interest argument, and one that has come up judicially and legislatively, is patient choice. If a patient has confidence in the referring OD and has a long and happy relationship with him, they can choose to do their routine follow-up care with him or her. It may also be that these elderly patients live much closer to the referring OD than they do the surgery center and/or OMDs office, and prefer to minimize their driving time, or distance their sons/daughters have to drive them.

Also, in selected rural areas, patients may go to the big city for surgery, which could be a drive of several hours. It's a great patient inconvenience to have to do that multiple times. Heck, even the AAO sees that as a reason for co-management.

In an effort to be 'fair and balanced', the one thing no one has mentioned is that ODs want to sell glasses. If the OMD sees the patient for 90 days, sooner or later they're going to hand over an Rx, because anisometropic patients get grumpy. ODs in general prefer to get the patient back before any Rx is written so they can write the Rx themselves. This is NOT the only reason behind the OD co-management, but it's naive to assume it's not a factor.

This is another place where Dr. Doan's suggestion for OMDs to limit dispensing would help everyone get along and play nice.

Tom Stickel, OD

This is absolutely the spirit in which co-management rules were written, and it's what I follow in comanaging my patients. There are two reasons for this. One is that I want the patient to feel they can come to me for post-op care if they choose (and many do). Some of my patients, however, want to get back to their optom ASAP because they love him/her, or because my outlying site is 45 minutes away. The second reason is that comanagement is under the microscope because, as in situations like Ben describes, some comanagement agreements come pretty darn close to fee-splitting. This means that the surgeon always sends the patient back because it is understood that the optometrist will share in the profit (admittedly not much profit). As Ben pointed out, this is as unethical as some of the old-time outright "I'll pay you for referrals" situations.

None of my referring optometrists have threatened (like Ben) to cut the nuts off of my practice becuase I didn't comanage a patient. That's what's wrong with some of the analogies being thrown around. Pick whatever credit card gives you miles, certainly, as long as you don't then threaten to firebomb the competitor's offices for not giving you the same offer.

 

[iloveoptometry]

I don't think you'll regret it. I DO think we have a responsibility to support the AAO and our PAC in order to maintain high-quality patient care and patient safety.

Is their whole argument access to care? Certainly ther have to be enough ophthalmologists in the state to do cataracts, right? They have to drive a few hours to get their coronary bypass or hip replacement too right? Anybody want to take the hit and move to Oklahoma? (I hear the weather is nice there )

high quality patient care or high profits for ophthamologist?

 

[Andrew_Doan]

high quality patient care or high profits for ophthamologist?

Both. Why shouldn't skilled surgeons be paid well?

Knowledge and expertise is worth money.