Optometry and Prescriptions

[JennyW]

If you read my story above, then you will understand that it's the lack of standardized residency training and contact with ill patients in a hospital setting that makes OD less capable of prescribing systemic medications.

Yes, I agree that removing a chalazion is different than doing intraocular, orbital, or periorbital surgery. If optometrists would like to expand their scope of practice, then I think it may be reasonable to form a joint board consisting of MDs, DOs, and ODs to determine what procedures and by what mechanisms these procedures will be taught to optometry. To date, there is no such board; thus, all surgical procedures, minor and major, should be reserved for physicians and surgeons trained to perform them.

What angers me and my colleagues is instead of forming a working relationship with ophthalmologists, optometry will aggressively lobby for legislation that grants them privileges. Read the new optometry law in Oklahoma. It's more than just chalazions the Oklahoma optometrists are seeking.

In theory, that's not a bad idea, but in practice, I'm not so sure it would work well.

Unfortunately, ODs and OMDs have generally had a fractured relationship. From the time ODs wanted to expand their scope of practice to be able to check IOPs and do dilations, it has been a problems.

If you read some of the letters to the editor, and some of the position papers put out by the AAO from that time, the contention was that ODs would be at best blinding patients with proparacaine, and at worst, killing them with tropicamide. This probably set the stage for a poor relationship, and that is unfortunate.

Even today, in my home state of New York, OMDs are constantly going to court to have the removal of foreign bodies restricted because that's "surgery, despite the face that ODs in New York have successfully removed thousands. And even though ODs had successfully managed thousands of glaucoma patients, when Xalatan became available, a lawsuit was filed by OMDs trying to restrict ODs from continuing to manage glaucoma because in the original legislative formularly, "prostaglandin analogs" were not part of the formulary, and since ODs couldn't use the "most advanced" drugs, then they should be prohibited from using any. That doesn't make much sense. As much as it is argued that ODs try to expand their scope of practice "with the stroke of a pen" OMDs are constantly trying to RESTRICT scope of practice of procedures that have been done successfully for years "with the stroke of a pen."

At one point in time, it was considered "unethical" for OMDs to teach in a school of optometry. OMDs who did this could be sanctioned by their academy. I don't think that is still the case today, but that goes to show some of the history.

A collegue of mine who moved from New York to Reno Nevada told me that even though ODs in Nevada are technically allowed to treat glaucoma, in order to be licensed in Nevada to do this, they have to successfully "co-manage" a certain number of patients with an OMD for 2 years. (I think he said 15 patients.) The OMD was then supposed to sign off that they agreed with the ODs diagnosis and treatment. Well, you can guess how many OMDs cooperated with this scenario. Though my collegue had worked in the VA for 8 years and treated hundreds of patients for glaucoma, no OMD would comanage with him. One of his patients he suggested putting on Timolol, the OMD disagreed and gave the patient Betimol. THe OD did not get "credit" for this case. He had a similar patient a few days later that he suggested Betimol for (since this seemed to be the OMDs drug of choice) and, you guessed it, the OMD switched it to Timolol. Again, no credit.

When he asked the OMD if there was any clinical reason to make these changes, the OMD admitted that there wasn't. He just felt like it.

So again, that's just an anecdotal story, but OMDs don't exactly have a reputation for working with ODs unless the OD is supplying a steady stream of patients. So, I'm not so sure that a joint board would be effective.

Jen

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[Anasazi23]

There is a similar battle brewing between the psychiatrists and psychologists. Unfortunately, the psychiatrist posters in that forum have much less solidarity than that of the ophthalmologists. Sadly, ophthalmologists will lose this battle slowly. Optometrists will take lessons from the underhanded manner in which psychologists pass their prescribing laws.

http://pn.psychiatryonline.org/cgi/content/full/39/10/1

No legislator wants to be caught with their pants down during election year with the attack: "So, councellor X, your record indicates that you voted to cut access to quality healthcare for seniors."

Of course, if you have the stamina to read through the 10+ pages of post, you may form a different opinion.

 

[aphistis]

Ok Bill.

If you substitute the word "dental" for the word "optometry" in your post, then your post would pretty much describe optometric training.

And I never meant to give the impression that optometric training allows for massively invasive procedures like the one Dr. Doan described earlier in this thread.

But it certainly provides for the removal of chalazions, foreign bodies, dialation and irrigation, and even *gasp* PIs and YAGs. These are procedures that have historically been considered "surgical."

How? Likely in the same way that dental is done. Through didactic training, clinical observation, and clinical performance under the supervision of experienced licensed faculty members, many of whom are ophthalmologists.

Jen

I'm in no position to pass judgment on where the line distinguishing optometry from opthalmology should be placed. However, I think you're confusing the actual scope of optometry relative to dentistry with what you think it *should* be.

I have no idea what chalazions are, what happens during a dilated exam, or what the acronyms PI or YAG even stand for; but I happen to agree strongly with Dr. Doan that essential criteria for scope-of-practice decisions should require the ability not only to perform the procedure normally, but also to manage complications that arise postoperatively.

Are optometrists qualified by that standard to do the things you mention? I have no idea. If so, then I have no grounds to object; if not, however, you owe it to your patients to swallow your pride, recognize your professional limitations, and refer to someone who *is* able to manage the patient's care.

 

[maxwellfish]

but I happen to agree strongly with Dr. Doan that essential criteria for scope-of-practice decisions should require the ability not only to perform the procedure normally, but also to manage complications that arise postoperatively.

Bill, it is not my intention to drag you into this, I apologize, I merely would like to use your quote because this discussion seems to have gone astray...

I think everyone's ears perked up when the comment was made that- yes managing complications is a requirement and look at how well the dentists do it, they are trained similar to MD/DO, blahblah, but optometrists, no way, they are not trained correctly and haphazardly prescribe with no regard.

Then we compared training and what it takes, blah blah there are differences, but to say that the dental education trains dentists to prescribe medications within their scope yet realizing systemic conditions and the like, and the optometric education doesn't seems incorrect to me.

I think what I'm getting at is, it is my opinion that optometry should be able to serve its patients to the fullest scope, including the use of medications... If the training is under question, then steps should be made to make it adequate but to simply say "They are not trained like us, so no they are doing it wrong" is an incorrect assumption or even conclusion in this case


my humble two

 

[shredhog65]

bottom line on this one. OD's are not medically trained. It takes a deep understanding of the entire human body to correctly and safely dispense medication. OD's lack this. MD's complete an entire residency (4 years + more with fellowship) in order to perfect their surgical and medical skills. OD's do not. Until OD's start training this way, they will not be qualified to do the things ophthalmologists do.

OD's are very good at what they're trained to do. They're excellent at prescribing lenses, fitting contacts, low vision, etc. What they are not (as a whole) very good at is medical and surgical treatment of disease. There is a reason you get an MD, and there is a reason you get an OD. I know an OD who went to medical school in order to become an ophthalmologist. This person did this because med school and residency provide the training they needed to be compitent at medical and surgical diagnosis & treatment - OD school/ training did not.

bottom line - if you want to do the things that an ophthalmologist does, then go to medical school and get an ophtho residency. OD school doesn't train you effectively.

 

[maxwellfish]

bottom line on this one. OD's are not medically trained. It takes a deep understanding of the entire human body to correctly and safely dispense medication. OD's lack this. MD's complete an entire residency (4 years + more with fellowship) in order to perfect their surgical and medical skills. OD's do not. Until OD's start training this way, they will not be qualified to do the things ophthalmologists do.

OD's are very good at what they're trained to do. They're excellent at prescribing lenses, fitting contacts, low vision, etc. What they are not (as a whole) very good at is medical and surgical treatment of disease. There is a reason you get an MD, and there is a reason you get an OD. I know an OD who went to medical school in order to become an ophthalmologist. This person did this because med school and residency provide the training they needed to be compitent at medical and surgical diagnosis & treatment - OD school/ training did not.

bottom line - if you want to do the things that an ophthalmologist does, then go to medical school and get an ophtho residency. OD school doesn't train you effectively.

ODs only do OD things and OMDs only do OMD things... I don't think so

regarding medication, again I think what you are saying is "ODs dont do it like MDs, so no they can't do it"... so just to put you to task, you stated earlier that dentists are trained in the "correct way to dispense systemic medication" and just now that it takes "deep understanding of the entire human body" doesn't describe dentists to me, but I dont want to get into that I just want to point out that it only seems to raise suspicion when there is a turf war at hand. hmmm

 

[shredhog65]

The supervision in dental school is similar to the relationship between medical students and attending physicians, not residents and attending physicians.

Medical residents can write orders and prescriptions without attending approval but under attending supervision.

I'm curious. Do dentists manage any systemic illnesses?

I think the main point is that dentists are trained for a surgical career with limited medical privileges. Similar to medicine, this training has been tested, strengthened, and proven for over 100 years. In addition, if dental graduates desire to perform more invasive surgeries then there are dental surgical fellowships and OMFS residencies. The OMFS residents complete a transitional year and work with medical residents. I worked with OMFS residents on the cardiology service. They also take call with us and manage patients.

i think this sums it up. as for dentists managing systemic illnesses - i am not a dentist, but my grandfather is, and he has diagnosed (not managed though) many systemic diseases - especially autoimmune plus coagulopathies/ and hematopeitic disturbabnces. i guess the amount of bleeding during proceedures can tell you alot.

 

[maxwellfish]

i think this sums it up. as for dentists managing systemic illnesses - i am not a dentist, but my grandfather is, and he has diagnosed (not managed though) many systemic diseases - especially autoimmune plus coagulopathies/ and hematopeitic disturbabnces. i guess the amount of bleeding during proceedures can tell you alot.

Do you think they just set OD students loose... They spend at least their fourth year, in its entirety, involved in the same type of relationship.

 

[Andrew_Doan]

Even today, in my home state of New York, OMDs are constantly going to court to have the removal of foreign bodies restricted because that's "surgery, despite the face that ODs in New York have successfully removed thousands. And even though ODs had successfully managed thousands of glaucoma patients, when Xalatan became available, a lawsuit was filed by OMDs trying to restrict ODs from continuing to manage glaucoma because in the original legislative formularly, "prostaglandin analogs" were not part of the formulary, and since ODs couldn't use the "most advanced" drugs, then they should be prohibited from using any. That doesn't make much sense. As much as it is argued that ODs try to expand their scope of practice "with the stroke of a pen" OMDs are constantly trying to RESTRICT scope of practice of procedures that have been done successfully for years "with the stroke of a pen."

At one point in time, it was considered "unethical" for OMDs to teach in a school of optometry. OMDs who did this could be sanctioned by their academy. I don't think that is still the case today, but that goes to show some of the history.

A collegue of mine who moved from New York to Reno Nevada told me that even though ODs in Nevada are technically allowed to treat glaucoma, in order to be licensed in Nevada to do this, they have to successfully "co-manage" a certain number of patients with an OMD for 2 years. (I think he said 15 patients.) The OMD was then supposed to sign off that they agreed with the ODs diagnosis and treatment. Well, you can guess how many OMDs cooperated with this scenario. Though my collegue had worked in the VA for 8 years and treated hundreds of patients for glaucoma, no OMD would comanage with him. One of his patients he suggested putting on Timolol, the OMD disagreed and gave the patient Betimol. THe OD did not get "credit" for this case. He had a similar patient a few days later that he suggested Betimol for (since this seemed to be the OMDs drug of choice) and, you guessed it, the OMD switched it to Timolol. Again, no credit.

Jen,

You make very good points. Perhaps we need new leadership on both sides to develop a working relationship and stop this ridiculous fighting between our professions. I strongly believe that the solution may be found in our professions working together.

I think optometrists can manage minor problems with drops and oral meds. However, optometrists must also realize their limits. Certain medications like oral prednisone and immunosuppressives should only be used by medical doctors who have treated thousands of patients with these medications. The nature of our profession divides the patient population into two groups:mainly healthy individuals and others who have serious pathology. Optometrists do a wonderful job screening and treating minor pathology in the group consisting of mainly healthy individuals, and ophthalmologists are competent with treating patients with serious pathology. This is not because optometrists are "less intelligent" but rather it's a manifestation of the differences in our training programs.

Furthermore, it's interesting that there are groups of optometrists who want more medical privileges, but there are many who will not accept responsibility in court. Many of my faculty have been expert witnesses, and when the optometrist is sued, he/she often claims that it's not within his/her scope of practice. The lawyers then go after the physician instead. This is one of the main reasons why optometrists can claim years of no complications and pay only $400/year in malpractice.

 

[Tony.]

wow!
SDN ophthalmology threads are WAAAY more interesting than the OD threads....

 

[shredhog65]

I think optometrists can manage minor problems with drops and oral meds. However, optometrists must also realize their limits. Certain medications like oral prednisone and immunosuppressives should only be used by medical doctors who have treated thousands of patients with these medications. The nature of our profession divides the patient population into two groups:mainly healthy individuals and others who have serious pathology. Optometrists do a wonderful job screening and treating minor pathology in the group consisting of mainly healthy individuals, and ophthalmologists are competent with treating patients with serious pathology. This is not because optometrists are "less intelligent" but rather it's a manifestation of the differences in our training programs.

Furthermore, it's interesting that there are groups of optometrists who want more medical privileges, but there are many who will not accept responsibility in court. Many of my faculty have been expert witnesses, and when the optometrist is sued, he/she often claims that it's not within his/her scope of practice. The lawyers then go after the physician instead. This is one of the main reasons why optometrists can claim years of no complications and pay only $400/year in malpractice.

great post

 

[cpw]

to clarify the debate about residencies for optometrists.. there's no WAY it's 40% of graduating ODs. Like the early post said there are only 130 slots for residency.. and in my fouth year class there are only 10 students thinking of applying for one. (which is only 13% of my class).

 

[scott McGregor]

This was posted in the optometry forum.

http://forums.studentdoctor.net/showthread.php?t=123623
http://www.revoptom.com/drugguide.asp?show=view&articleid=2

I find it rather disturbing when an article "teaches" optometrists how to prescribe medications like prednisone without much emphasis on the systemic side effects.

"Optometric physicians and their patients are enjoying the huge benefits of topically applied medications. Now it's time to fully embrace a different route of administration: the orally administered medicines. So that we can put this subset of drugs in perspective, realize that the internist must master hundreds of medicines; we only need to master a baker's dozen (give or take) to treat the vast majority of ophthalmic diseases."

The term optometric physicians appears again. Way to blur the lines even more!

Dr Doan,
Would you please post the type/amount and number of cases managed that allows you to fit rigid gas permeable lenses on an irregular astigmatic patient. Improper fit could lead to scarring and resultant PK transplant. Also same question for number of cases you personally fit the patient with eyeglasses, including all seg height measurments, PD and lens decentration, as well as you advice on which progressive add to use. Perhaps I should address this to the Contact Lens Association of Ophthalmologists or the Dispensing Ophthalmologist Association. WHO is blurring the lines??

 

[Andrew_Doan]

I agree with the above. I don't think ophthalmologists should dispense glasses or contact lenses. In a symbiotic world, there should be lines drawn for surgery as well as dispensing glasses.

 

[scott McGregor]

Jen,

You make very good points. Perhaps we need new leadership on both sides to develop a working relationship and stop this ridiculous fighting between our professions. I strongly believe that the solution may be found in our professions working together.

Furthermore, it's interesting that there are groups of optometrists who want more medical privileges, but there are many who will not accept responsibility in court. Many of my faculty have been expert witnesses, and when the optometrist is sued, he/she often claims that it's not within his/her scope of practice. The lawyers then go after the physician instead. This is one of the main reasons why optometrists can claim years of no complications and pay only $400/year in malpractice.

Dr Doan
I guess I don't understand your comment above. An OD treats a patient, it causes such complications that the OD is sued. The OD stands in court and says "Its not within my scope"?? The law has Ipso-Facto rule that says "the thing speaks for itself"--You Did It !!. You can't do something, then claim it was out of your scope as a defense. Could the low claim rate and low cost of malpractice be because---when practicing primary care, ODs are doing a good job??!! (I have 2 million/occurance for $800/yr. AND specific clauses that prevent coverage for surgery (as traditionally defined). If I step outside my scope, I'm not even covered.

 

[Ben Chudner]

Dr Doan
I guess I don't understand your comment above. An OD treats a patient, it causes such complications that the OD is sued. The OD stands in court and says "Its not within my scope"?? The law has Ipso-Facto rule that says "the thing speaks for itself"--You Did It !!. You can't do something, then claim it was out of your scope as a defense. Could the low claim rate and low cost of malpractice be because---when practicing primary care, ODs are doing a good job??!! (I have 2 million/occurance for $800/yr. AND specific clauses that prevent coverage for surgery (as traditionally defined). If I step outside my scope, I'm not even covered.

I read that and was confused as well. The only time an OD would be able to say it was beyond his/her scope would be if it truely was and the patient was referred to the proper OMD and that OMD made a mistake. For example, if I have a patient with advanced glaucoma with IOP's of 28 OU on three meds I would refer to the glaucoma specialist in town. If the patient goes blind while in her care and then he sues, I will be named as well. My defense will be that the patient needed surgical intervention and that is beyond my scope. My referral to the glaucoma specialist was the correct course of action, and I am not liable once she assumed care for the patient (as long as I correctly managed the IOP until it no longer responded to medical therapy). In that case I would be saying "it was not within my scope" not because I performed a trab and it failed, but because I am not allow to perform trabs, so I did not. I have never heard of a case where an OD performed a procedure, made a mistake and then claimed no liability because it was not within his scope. If it wasn't within his scope, not only would he still be liable, but he would have also been guilty of practicing medicine without a license.

 

[Tony.]

to clarify the debate about residencies for optometrists.. there's no WAY it's 40% of graduating ODs. Like the early post said there are only 130 slots for residency.. and in my fouth year class there are only 10 students thinking of applying for one. (which is only 13% of my class).

cpw,
this is just a side question:
is there a discussion about OD residencies on the forum? advantages/disadvantages? where can i go to read up on that?
and on a personal note, can you tell me again whether you've decided to do a residency?

 

[Andrew_Doan]

Dr Doan
I guess I don't understand your comment above. An OD treats a patient, it causes such complications that the OD is sued. The OD stands in court and says "Its not within my scope"?? The law has Ipso-Facto rule that says "the thing speaks for itself"--You Did It !!. You can't do something, then claim it was out of your scope as a defense. Could the low claim rate and low cost of malpractice be because---when practicing primary care, ODs are doing a good job??!! (I have 2 million/occurance for $800/yr. AND specific clauses that prevent coverage for surgery (as traditionally defined). If I step outside my scope, I'm not even covered.

Consider this scenario, OD misses diagnosis, patient gets treated via surgery by a surgeon, and the outcome is bad because the disease is advanced. Lawyer and patient sues surgeon and OD. OD claims it is beyond scope and states that the MD is the expert. There is jury that likes the patient and the surgeon has to pay. It happens like this all the time.

 

[VA Hopeful Dr]

Consider this scenario, OD misses diagnosis, patient gets treated via surgery by a surgeon, and the outcome is bad because the disease is advanced. Lawyer and patient sues surgeon and OD. OD claims it is beyond scope and states that the MD is the expert. There is jury that likes the patient and the surgeon has to pay. It happens like this all the time.

It seems like this same scenario could be played about between primary care physicians and other various surgeons/specialists as well. Does this "blame the guy higher up the line" mentality happen outside optometry/ophthalmology?

 

[Tom_Stickel]

Consider this scenario, OD misses diagnosis, patient gets treated via surgery by a surgeon, and the outcome is bad because the disease is advanced. Lawyer and patient sues surgeon and OD. OD claims it is beyond scope and states that the MD is the expert. There is jury that likes the patient and the surgeon has to pay. It happens like this all the time.

Dr. Doan,

As usually happens on these boards, I'm going to have to ask for something more than "it happens all the time", anecdotal evidence. Is it possible that the surgeon AND the OD have to pay, but since you know the surgeons better than the ODs, you don't hear about the judgments against them?

I do agree that juries often have little grasp of the complexities of these cases, e.g. bad disease often equals bad surgical outcome. But for the OD to get off the hook is wrong, IF they missed disease early.

And some of these cases might not be the ODs fault on closer inspection. For example, patient presents with flashes/floaters, OD does scleral depression, no breaks seen, follow up scheduled. Over next week, patient develops macula off detachment from fresh break but fails to call OD (thought it would get better syndrome). At your university clinic, I'd imagine you tend to see these kinds of disasters. So maybe in some of these cases there was no disease to miss or misdiagnose at initial presentation.

Again, just playing devil's advocate and asking for more than anecdotal evidence.

Tom Stickel
Indiana U. School of Optometry, 2001

 

[rpie]

I read that and was confused as well. The only time an OD would be able to say it was beyond his/her scope would be if it truely was and the patient was referred to the proper OMD and that OMD made a mistake. For example, if I have a patient with advanced glaucoma with IOP's of 28 OU on three meds I would refer to the glaucoma specialist in town. If the patient goes blind while in her care and then he sues, I will be named as well. My defense will be that the patient needed surgical intervention and that is beyond my scope. My referral to the glaucoma specialist was the correct course of action, and I am not liable once she assumed care for the patient (as long as I correctly managed the IOP until it no longer responded to medical therapy). In that case I would be saying "it was not within my scope" not because I performed a trab and it failed, but because I am not allow to perform trabs, so I did not. I have never heard of a case where an OD performed a procedure, made a mistake and then claimed no liability because it was not within his scope. If it wasn't within his scope, not only would he still be liable, but he would have also been guilty of practicing medicine without a license.

I agree Ben; an OD will get sued along with the OMD when a liability suit is filed. In most malpractice cases lawyers go after everyone, even a PCP if they can. Lawyers assess the % of fault each doctor had in contributing to the patient’s ill fate. The OMD will have the largest percentage because they were the last person that treated the patent. This would also be the case if the OD were the last person to treat the patient. Another interesting note is that OD’s will get slapped a healthy liable percent for making the wrong referral. I know an OD that was found 35% liable for referring an RD, macula off to general OMD and not directly to a retinal sub-specialist.

 

[cpw]

cpw,
this is just a side question:
is there a discussion about OD residencies on the forum? advantages/disadvantages? where can i go to read up on that?
and on a personal note, can you tell me again whether you've decided to do a residency?

I considered doing a residency and then decided against it. Many of my classmates decided to do one in various fields. many of them are under the dilusion it's going to help them find jobs in already saturated areas. While it might , it's no guarantee. If doctors like you, you'll find somewhere to work. (either through personal searching, or word of mouth.... optometry is not that big of a ballgame)

I personally, had offers to work after my fourth year externships. So, doing a residency wasn't going to make me more competitive and I'm learning tons working with residency trained ODs. But, I do plan on trying to get into the FAAO. (they do have the best CE locations)

There usually is a residency discussion on the forum. Try doing a SDN search for previous conversations.

 

[rubensan]

It seems like this same scenario could be played about between primary care physicians and other various surgeons/specialists as well. Does this "blame the guy higher up the line" mentality happen outside optometry/ophthalmology?

Yes this happens within the realm of nurse midwifes and OB/GYNs with frequency.

 

[ReMD]

After reading these threads, I think it is scary that any health care professional that has not completed a medical internship, would prescribe systemic meds, like prednisone and/or abx.

Those that do this have absolutely no clue about all the serious adverse rxns that can happen. After completing 4 yrs of medical school training, I was still so unprepared to treat pts with systemic meds (even the so called benign ones) at the start of my internship year.

One can read an entire textbook about the adverse effects of certain meds but it really is not until you see these things that you can truly identify them.

Cushing's syndrome, secondary adrenal insuff, c-diff colitis, liver failure, renal failure, syncope, hemolytic anemia, heart failure, so on and so on. I have seen and treated these diseases, all of which were drug induced.

The privilege to rx systemic meds should not be taken so lightly. Giving a med even like NSAIDs can cause very severe problems (ie, ARF in the elderly).

Would an OD know to ask a pt if they were on an ACE-I prior to starting an NSAID?

Prednisone and certain abx can cause even worse problems. It is impossible to recognize these effects, when you have never seen it.

Also, what about all the other meds the pt is on? Would an OD know about the various interactions/contraindications when dealing with multiple other non ocular systemic meds?

Simply referring to the primary doc is a poor answer. The issue is to recognize the risks or the development of these adverse effects and choose the correct med or make the appropriate changes before the problem arises.

There is no question in my mind that an OMD is better qualified to rx systemic meds than an OD. If you do not agree, then I welcome you to shadow a medical intern and see for yourself the difference in training.

 

[rubensan]

After reading these threads, I think it is scary that any health care professional that has not completed a medical internship, would prescribe systemic meds, like prednisone and/or abx.

Uh-oh.....I'm bracing for the storm that is sure to follow this post I agree with you on many points ReMD, but my experience has been that these are difficult points to impress upon those health care professionals who have not completed (or plan to complete) a medical or surgical internship. These forum wars, though entertaining usually degenerate into comparing OD vs OMD education, name calling and putting many of the ODs on the defensive re: their own education (how many times do we need to hear that so and so graduated magna cum laude from such and such ivy league? ). A little unsolicited advice: one wise person on this forum once told me to focus our attentions on "drawing the line at surgery." When you look at many of the OD vs. OMD battles from this perspective, I find it easier to concede some of these other issues.

 

[futuredoctorOD]

After reading these threads, I think it is scary that any health care professional that has not completed a medical internship, would prescribe systemic meds, like prednisone and/or abx.

Those that do this have absolutely no clue about all the serious adverse rxns that can happen. After completing 4 yrs of medical school training, I was still so unprepared to treat pts with systemic meds (even the so called benign ones) at the start of my internship year.

One can read an entire textbook about the adverse effects of certain meds but it really is not until you see these things that you can truly identify them.

Cushing's syndrome, secondary adrenal insuff, c-diff colitis, liver failure, renal failure, syncope, hemolytic anemia, heart failure, so on and so on. I have seen and treated these diseases, all of which were drug induced.

The privilege to rx systemic meds should not be taken so lightly. Giving a med even like NSAIDs can cause very severe problems (ie, ARF in the elderly).

Would an OD know to ask a pt if they were on an ACE-I prior to starting an NSAID?

Prednisone and certain abx can cause even worse problems. It is impossible to recognize these effects, when you have never seen it.

Also, what about all the other meds the pt is on? Would an OD know about the various interactions/contraindications when dealing with multiple other non ocular systemic meds?

Simply referring to the primary doc is a poor answer. The issue is to recognize the risks or the development of these adverse effects and choose the correct med or make the appropriate changes before the problem arises.

There is no question in my mind that an OMD is better qualified to rx systemic meds than an OD. If you do not agree, then I welcome you to shadow a medical intern and see for yourself the difference in training.

Being a person who belives in science and the scientific method---I have learned not to accept sweeping broad generalizations because they tend to be flawed. Podiatrists, Dentists, and Optometrists all prescribe systemic drugs within a limited formulary designated by their scope of practice. This is done safely in most cases (just as medical physicians do within a broader scope.) The eye doctor (Doctor of Optometry) I work with writes oral scripts on a regular basis being affiliated with the local Eye Institute he treats a lot of primary eye disease by way of medical management. He completed a 1 year residency after Optometry school which focused on medical management of eye disease (this includes management of systemic conditions that affect the ocular system.) This is 5 years total to treat safely within a limited scope of practice--the ocular system and associated systemic conditions. Your "medical education" example is sooo tired and overstated because it is flawed. Why is it flawed? because you are making assumptions throughout it-----example, "Would an OD know to ask a pt if they were on an ACE-I prior to starting an NSAID?---the answer to this question after asking two OD's I work with is ABSOLUTELY! I will start attending Optometry school next year so I will concede to the wealth of medical knowledge you MUST have BUT I have taken statistics and quite a few graduate level science courses and must offer some advice to you.....You need facts---not assumptions.....Did you survey a representative sample of OD's and ask them, "Would an OD know to ask a pt if they were on an ACE-I prior to starting an NSAID?" You are an MD for god sakes----you understand the concept of "the burden of truth." You seem to be very intelligent but you lack respect for the optometric profession's training and abilities and in a way insulted every OD that I know who writes these evil systemic drugs on a regular basis safely----what gives man?

 

[rubensan]

ahhh, futuredoctorOD, i forgot about you! how i missed your posts! well, welcome back how's your shadowing going? you must be very excited about becoming a genuine futuredoctorOD soon!

Well anyhooo....Cheers,

 

[aphistis]

After reading these threads, I think it is scary that any health care professional that has not completed a medical internship, would prescribe systemic meds, like prednisone and/or abx.

Those that do this have absolutely no clue about all the serious adverse rxns that can happen. After completing 4 yrs of medical school training, I was still so unprepared to treat pts with systemic meds (even the so called benign ones) at the start of my internship year.

One can read an entire textbook about the adverse effects of certain meds but it really is not until you see these things that you can truly identify them.

Cushing's syndrome, secondary adrenal insuff, c-diff colitis, liver failure, renal failure, syncope, hemolytic anemia, heart failure, so on and so on. I have seen and treated these diseases, all of which were drug induced.

The privilege to rx systemic meds should not be taken so lightly. Giving a med even like NSAIDs can cause very severe problems (ie, ARF in the elderly).

Would an OD know to ask a pt if they were on an ACE-I prior to starting an NSAID?

Prednisone and certain abx can cause even worse problems. It is impossible to recognize these effects, when you have never seen it.

Also, what about all the other meds the pt is on? Would an OD know about the various interactions/contraindications when dealing with multiple other non ocular systemic meds?

Simply referring to the primary doc is a poor answer. The issue is to recognize the risks or the development of these adverse effects and choose the correct med or make the appropriate changes before the problem arises.

There is no question in my mind that an OMD is better qualified to rx systemic meds than an OD. If you do not agree, then I welcome you to shadow a medical intern and see for yourself the difference in training.

You'd better make sure you never visit the dentist, then. God only knows the horrors that may ensue.

 

[I Surgeon]

You'd better make sure you never visit the dentist, then. God only knows the horrors that may ensue.

I don't believe Dentists will be using prednisone, but correct me if I'm wrong.
Antibiotics and some pain meds are all dentists have to worry about. I don't believe too many horrors will happen with antibiotics or the pain meds Dentists are allowed to use.

 

[aphistis]

I don't believe Dentists will be using prednisone, but correct me if I'm wrong.

Consider yourself corrected, then.

Antibiotics and some pain meds are all dentists have to worry about. I don't believe too many horrors will happen with antibiotics or the pain meds Dentists are allowed to use.

I'd recommend double-checking your sources on this one.

 

[I Surgeon]

Consider yourself corrected, then.


I'd recommend double-checking your sources on this one.

Give me an example that a dentist (not oral surgeon) would use prednisone, especially on a regular basis.

Correct me, then sir!

 

[aphistis]

(not oral surgeon)

I wasn't thinking of oral surgeons, actually...but since you brought them up, are you suggesting they aren't dentists?

Give me an example that a dentist would use prednisone.

Pemphigus vulgaris, cicatricial pemphigoid, lichen planus, SLE, oral submucous fibrosis, Kaposi's, Sjogren's, candidiasis, oral surgery, the list goes on.

Look, I'm not here to start a pissing contest with anybody. You wanted some examples; I'm giving you some. If you're satisfied, that's great If you're not, go do the research yourself. I'm not going to waste time arguing an issue that's already conclusively settled.

 

[rubensan]

Pemphigus vulgaris, cicatricial pemphigoid, lichen planus, SLE, oral submucous fibrosis, Kaposi's, Sjogren's, candidiasis, oral surgery, the list goes on.

Once again, thanks for educating us Bill! (genuinely stated, no sarcasm here)

Look, I'm not here to start a pissing contest with anybody.

This I find hard to believe given your track record on this forum.

 

[jchod]

Once again, thanks for educating us Bill! (genuinely stated, no sarcasm here)



This I find hard to believe given your track record on this forum.

I'll second that. Home-slice here spends more time on optom and ophtho forums than anywhere!

 

[I Surgeon]

I wasn't thinking of oral surgeons, actually...but since you brought them up, are you suggesting they aren't dentists?


Pemphigus vulgaris, cicatricial pemphigoid, lichen planus, SLE, oral submucous fibrosis, Kaposi's, Sjogren's, candidiasis, oral surgery, the list goes on.



Look, I'm not here to start a pissing contest with anybody. You wanted some examples; I'm giving you some. If you're satisfied, that's great If you're not, go do the research yourself. I'm not going to waste time arguing an issue that's already conclusively settled.

They are dentists, but they have more extensive training in dealing with medications. 85% of them have a MD and of course, they have experience dealing with surgical patients, not minor dental procedures.

I'm sure dentists see this stuff everyday. (sarcasm) Anyway, if you were to see any of these problems, I hope you would refer to this your local family physician, especially Kaposi's .

Oh, and by the way, steroids (prednisone) cause candidiasis especially in the mouth (asthma meds). They would exacerbate the problem. Clotrimazole is what should be used. Maybe you should spend more time learning Pharmacology than contibuting "excessively" to a Doctor's forum.

Good luck to you in your wanna-be physician practice.

 

[futuredoctorOD]

They are dentists, but they have more extensive training in dealing with medications. 85% of them have a MD and of course, they have experience dealing with surgical patients, not minor dental procedures.

I'm sure dentists see this stuff everyday. (sarcasm) Anyway, if you were to see any of these problems, I hope you would refer to this your local family physician, especially Kaposi's .

Oh, and by the way, steroids (prednisone) cause candidiasis especially in the mouth (asthma meds). They would exacerbate the problem. Clotrimazole is what should be used. Maybe you should spend more time learning Pharmacology than contibuting "excessively" to a Doctor's forum.

Good luck to you in your wanna-be physician practice.

Look, I don't know who you think you are making a teenage like comment about Bill's chosen field "Good luck to you in your wanna-be physician practice." but I regret to inform you that Denitsts are physicians There is NO equivalent medical specialty in Allopathy so if you feel comfortable going to a family practice MD to have your teeth worked on (because you feel that Doctors of Dental Surgery are poorly trained in medications) than go right ahead! Instead of asking Bill to review Pharmacology, instead why dont you read a book on how to address other professionals in a professional manner. Now I am 31 and I am guessing that you are 23 or 24----start acting like it. If you plan on being a doctor of Medicine (MD)---than you had better grow up.

 

[rubensan]

Look, I'm not here to start a pissing contest with anybody.

I smell piss.

there is NO equivalent medical specialty in Allopathy so if you feel comfortable going to a family practice MD to have your teeth worked on than just say so! Instead of asking Bill to review Pharmacology, instead why dont you read a book on how to address other professionals in a professional manner.

You're right futuredocotrOD, there is no allopathic equivalent. But that's not what I2I said in his post. I believe he was implying that if a patient has Kaposi's sarcoma, they probably have a lot of other issues besides oropharyngeal (although very important) that need to be addressed...perhaps the patients underlying immune status, CD4 count, viral load, etc. Maybe we all need to do more reading !

 

[futuredoctorOD]

ahhh, futuredoctorOD, i forgot about you! how i missed your posts! well, welcome back how's your shadowing going? you must be very excited about becoming a genuine futuredoctorOD soon!

Well anyhooo....Cheers,

Hi there,

My shadowing is going great...I have seen many different ocular conditions thru the slit-lamp as an observer and I want to see more! I am in the application process soon and hope to get into at least 5-6 schools so I have a choice where to go....Research is another area of interest to me as is Pharmacology----I LOVE Pharmacology. I hope everything is going well with you and besh wishes.....

 

[futuredoctorOD]

Look, I don't know who you think you are making a teenage like comment about Bill's chosen field "Good luck to you in your wanna-be physician practice." but I regret to inform you that Denitsts are physicians There is NO equivalent medical specialty in Allopathy so if you feel comfortable going to a family practice MD to have your teeth worked on (because you feel that Doctors of Dental Surgery are poorly trained in medications) than go right ahead! Instead of asking Bill to review Pharmacology, instead why dont you read a book on how to address other professionals in a professional manner. Now I am 31 and I am guessing that you are 23 or 24----start acting like it. If you plan on being an effective doctor of Medicine (MD)---than you had better grow up.

 

[futuredoctorOD]

I smell piss.



You're right futuredocotrOD, there is no allopathic equivalent. But that's not what I2I said in his post. I believe he was implying that if a patient has Kaposi's sarcoma, they probably have a lot of other issues besides oropharyngeal (although very important) that need to be addressed...perhaps the patients underlying immune status, CD4 count, viral load, etc. Maybe we all need to do more reading !

Having an opinion is one thing and devaluing an entire field of medicine (Dentistry) is something else. That was out of line.....

How are you doing?

 

[rubensan]

Having an opinion is one thing and devaluing an entire field of medicine (Dentistry) is something else. That was out of line.....

How are you doing?

I'm fine...but ask me after a few weeks of wards as an intern. tx for asking, though.


You're right, but the blame shouldn't fall squarely on I2I's shoulders. Aphistis has a notorius history of coming onto this forum and interjecting in a condescending and confrontational manner. He's done it to me, he's done it to our moderators and he's doing it again. We're all mature adults and can handle it. But, FDrOD, since you are giving lectures on "being mature" today, how about this one? Bill, it's not what you say, it's how you say it. It's a free country and an open forum, but if you want to get your point across, i believe you are intelligent enough to do it in a way that doesn't incite "pissing contests." OTW, I think people on this forum have a hard time taking you seriously.

 

[ItsGavinC]

I don't believe too many horrors will happen with antibiotics or the pain meds Dentists are allowed to use.

But horrors occur with the antibiotics and pain meds that physicians use? Same drugs, same scripts, same problems, if such problems do occur. The dispensing clinician isn't waived from dealing with ramifications of drugs they write for, simply on the basis of degree.

 

[ItsGavinC]

85% of them have a MD and of course, they have experience dealing with surgical patients, not minor dental procedures.

Closer to 40%.

 

[aphistis]

They are dentists, but they have more extensive training in dealing with medications. 85% of them have a MD and of course, they have experience dealing with surgical patients, not minor dental procedures.

I'm sure dentists see this stuff everyday. (sarcasm) Anyway, if you were to see any of these problems, I hope you would refer to this your local family physician, especially Kaposi's .

Oh, and by the way, steroids (prednisone) cause candidiasis especially in the mouth (asthma meds). They would exacerbate the problem. Clotrimazole is what should be used. Maybe you should spend more time learning Pharmacology than contibuting "excessively" to a Doctor's forum.

Good luck to you in your wanna-be physician practice.

[shrug]

If you say so. I figured you've been spoiling for a fight this whole time, and like I said before, you'll have to fish somewhere else. I'm not going to argue with you about it.

 

[futuredoctorOD]

This was posted in the optometry forum.

http://forums.studentdoctor.net/showthread.php?t=123623
http://www.revoptom.com/drugguide.asp?show=view&articleid=2

I find it rather disturbing when an article "teaches" optometrists how to prescribe medications like prednisone without much emphasis on the systemic side effects.

"Optometric physicians and their patients are enjoying the huge benefits of topically applied medications. Now it's time to fully embrace a different route of administration: the orally administered medicines. So that we can put this subset of drugs in perspective, realize that the internist must master hundreds of medicines; we only need to master a baker's dozen (give or take) to treat the vast majority of ophthalmic diseases."

The term optometric physicians appears again. Way to blur the lines even more!

Dr. Doan,

With all due respect that article was meant to be just an informative piece---not a real clinical education on oral scripts! I think you took that article out of context.

 

[I Surgeon]

Look, I don't know who you think you are making a teenage like comment about Bill's chosen field "Good luck to you in your wanna-be physician practice." but I regret to inform you that Denitsts are physicians There is NO equivalent medical specialty in Allopathy so if you feel comfortable going to a family practice MD to have your teeth worked on (because you feel that Doctors of Dental Surgery are poorly trained in medications) than go right ahead! Instead of asking Bill to review Pharmacology, instead why dont you read a book on how to address other professionals in a professional manner. Now I am 31 and I am guessing that you are 23 or 24----start acting like it. If you plan on being a doctor of Medicine (MD)---than you had better grow up.

You need to read the begiining of the forum here...I asked what do Dentists use prednisone for...he mentioned candida, which steroids does not treat. There is no where you will find that Dentists are called physicians, PHYSICIANS ARE ONLY MDS. Many professionals call themselves Dr., thats fine I guess, I mean you can get a Phd in Botany and be called Dr., but only physicians=Medical degree. Get it straight

I did not say anyone was poorly trained in medications, i don't think dentists should be treating a systemic disease (AIDS) that a PHYSICIAN was trained to treat.

The reason I said pseudo-physican is because he seems to want to treat medical conditions in a dental setting.

In no way did I imply that a family doctor start involving themselves in the care of teeth.

 

[I Surgeon]

But horrors occur with the antibiotics and pain meds that physicians use? Same drugs, same scripts, same problems, if such problems do occur. The dispensing clinician isn't waived from dealing with ramifications of drugs they write for, simply on the basis of degree.

I agree, but used within dental context, they are not as much a problem.

 

[I Surgeon]

Having an opinion is one thing and devaluing an entire field of medicine (Dentistry) is something else. That was out of line.....

How are you doing?

Denistry is not a field of medicine, IT IS DENISTRY. I did not devalue any specialty, but if you want to be a Doctor,then go to medical school, PLEASE. Everyone seems to want the same respect (and money)as physicians without going through the rigors and responsibilities of extensive medical training. It was not out of line, it was honest.

 

[futuredoctorOD]

Denistry is not a field of medicine, IT IS DENISTRY. I did not devalue any specialty, but if you want to be a Doctor,then go to medical school, PLEASE. Everyone seems to want the same respect (and money)as physicians without going through the rigors and responsibilities of extensive medical training. It was not out of line, it was honest.

I just got off the phone with my brother who is SURGEON and he just remarked how he just came back from his eye doctor---his OPTOMETRIST and said that it will be really nice in 5 years when I graduate from OPTOMETRY School and become an eye doctor---the first one in the family. When I sprained my ankle----I went to my foot doctor---yep you guessed it ----my podiatrist---yes he is a doctor too! You really want to open this semantical pandoras box? Optometry school, Dental School, and Podiatry School are all extremely rigorous and making a blanket statement like you have is erroneous. The rigors of Medicine? How about the rigors of Dentistry? All these fields have similar RIGORS! lol Medicine is a very generalized term---all doctoral level professionals practice "medicine" in their own form and you need to just stop this semantical elitism. I have the utmost respect for MD's and DO's---my family has numerous iterations of the two degrees. Did you go to Dental School? or Optometry School? or Podiatry School? NO----you did not... You have no personal reference point to make a comparison....And by the way------IN THE HISTORICAL PAST THE TERM DOCTOR WAS USED ORIGINALY BY PHD'S NOT ALLOPATHY, OSTEOPATHY, CHIROPRACTIC, PODIATRY, OPTOMETRY, DENTISTRY, ETC....all these fields adopted the term doctor for the respect it carried....Allopathic medicine has done a very good job of marketing it's business over the last century and I have to give them credit for it...but the minute you try to say, incorrectly I might add, that DDS's, OD's, and DPM's are not doctors you appear to be very disrespectful to these specialists and to me----(I am working my ass off to get into a program and will continue that until I am an eye doctor and after that.) It is people like you that create the Oklahoma's (in regard to OD surgery) because of your elitist attitude...Now I respect your academic accomplishment but let's get real here and accept the fact that Dentistry is a field of medicine that is totally independent of your field.......Your field is NOT medicine in the generic--------it is ALLOPATHIC MEDICINE......You are an ALLOPATH---no more a doctor or less than a Dentist---(DOCTOR OF DENTAL SURGERY--DDS or DOCTOR OF DENTAL MEDICINE---DMD) I do respect your opinion and training.


PS---I checked----less than 40% of Oral Surgeons have MD's most of them only carry the OMFS designation---that must be soooooooooo scary to all those patients that are in danger because they don't have MD's We had better call the morgue and get all the slabs ready!

I Optometry and Ophthalmology

 

[rubensan]

I just got off the phone with my cousin who is in OPTOMETRY school and he just remarked how difficult it was and how he can't imagine going through what we go through in an allopathic medical school! Sorry man, I just can't ever resist repsonding to your posts because you are such an easy target on this forum.

In all seriousness, there is truth in much of what you've said (though to be fair, OK has a lot to do with greed on both sides: OD and OMD). But like I've told you before (and yes, this is unsolcited advice), keep shadowing and studying and working hard. Get into the best OD program you can and become the most awesome OD you can. Have your patients call you doctor and be proud that you are helping people see in this world. It's a great feeling to "do good for a living." And....if someone wants to run their mouth on this forum, just let them. Yeah, it's an open forum, but it's also an MD/DO forum, as long as they are not posting their opinions on an OD forum, what does it really matter to you at your stage of the game? Say what you have to say with intelligence and try not to incite riots by telling people that "they have some serious issues" or accusing what they are saying as having a "total lack of respect for an entire field." It just won't get you that far here and it's nauseating for those of us who really want to see this forum return to its original roots "Med students interested in ophthalmology trying to get info from residents etc on what the specialty is like, what programs are good, etc, and educational posts on pathology, etc." Do you really want to stand in the way of this? But then again, I am not a moderator, it's just one blogger's opinion.

I Optometry and Ophthalmology

I do too!