Political Ophthalmology 101

No one is watching you read this article, so take a very short moment and honestly answer these questions: (1) Why haven't I ever met with a state legislator? and (2) why do I not contribute money to my state's ophthalmology political action committee (PAC)? If you are like 70% or more of your fellow ophthalmologists, you have never gotten politically involved.

There are lots of knee-jerk answers people give when asked to call a legislator: they are too busy; they do not like or trust politicians; or the problem is someone else's. Those who do get involved politically worry about who will find out and what the economic consequences may be. Although these are all reasonable responses, they are not without a valid retort.

Improving Efforts via Positive Actions
When you look at issues such as lifting the ban on assault weapons and the recent repeal of the bill in Pennsylvania that mandated helmets for motorcycle drivers, you can certainly lose faith in the political system's being grounded in common sense and logic. Therefore, it is not surprising that an issue such as eye surgery's being performed by individuals who have not completed medical school becomes a legislative reality. Having lost recent legislative battles in my own state of New Jersey, I am often asked why ophthalmology seems to be losing so many political disputes despite the fact that, in all good sense and logic, it is on the right side of the issues.

Lobbying, in some form, has been an honored specialty of the political system. Whether it is the AMA, the AAO, or state specialty societies, organized medicine uses the lobby to represent its interests, as does any other special interest group. Optometry uses a lobby to represent its perspective but appears to have a more carefully planned strategy than the aforementioned organizations. Essentially, optometry is organizing toward “yes,” and ophthalmology is organizing toward “no.” It is much easier to get people involved if you ask them to do something positive that will improve their lot. Optometry, by attempting to advance its scope of practice, has everything to gain and nothing to lose. However, the losers will be the unsuspecting patients who chose to see an optometrist and are unaware of the practitioner's lack of extensive clinical training as well as the absence of protection this affords patients.

It is hard to ask people to become active in an effort that could appear to be self-serving. Organized optometry had a major coup de guerre when it characterized the impending contests between ophthalmologists and optometrists as a “turf battle.” There is not a media source around that has not used that terminology to describe ophthalmology's effort to halt optometry's legislative expansions. The fact is that, although the economics of this issue are important, ophthalmologists have often failed miserably to communicate that our positions are in the patients' best interest and are based on our valuation of thorough medical, surgical, and clinical education.

Lobbying Rewards
The optometric lobby has had many distinct advantages. It is heavily funded by a group of optometrists, all of whom believe in its mission. While in school, optometrists learn about the ultimate benefit of grassroots activities. Nearly every optometrist decides to play some role and make some contribution politically. Dollars are only part of the picture. Politicians respond to their constituents, votes, and interests. Helping the politician to become elected or re-elected is no small part of the process. Continuously hammering away at issues enforces the “sincerity” of the optometrists' position. Optometrists are tireless and tenacious, and they show up with their dollars.

The optometric associations' members are available, on short notice, to appear at legislators' offices, in legislative committee hearings, or at fundraisers. They also have a constant presence in the halls of the state houses. Legislators actually know most of the political optometric leaders.

OPHTHALMOLOGY'S POLITICAL ROLE
Because ophthalmologists are busy doing the job for which they were trained in medical school, they are often unable to shuffle or reschedule patients when called upon on short notice. Still, there is always time to squeeze in something important. Maybe you are not the ophthalmologist to ask to show up in the state capitol on 2 days' notice, but you certainly can call, write to, or make an appointment to visit a legislator during your planned free time. You could attend a legislator's fundraiser and meet other constituents from your district. I cannot overemphasize how important it is that a legislator recognize your face and name and know that you are available, if needed, to answer his questions on health issues. Your state ophthalmologic society can send you reams of information that you can communicate to legislators regarding issues of pertinence to ophthalmology.

IS MEDICAL SCHOOL A MYTH?
Optometrists' first successes ultimately began when diagnostic drugs were approved throughout the states. The huge issue of Therapeutic Practice Acts expansion transformed optometry from an optical science to an allied health profession and allowed the optometric lobby to start on a trail of diagnosis and subsequent medical (and now surgical) treatment. The Therapeutic Practice Acts, although varied in scope, have broadened optometric scope of practice nationwide, starting with topicals, moving to oral medicines, followed by narcotics and an anomalous debacle in Oklahoma with laser therapy in 1998, and culminating in incisional surgical privileging in 2004. Optometry was ostensibly based on the optical sciences; it was never intended to intrude into the practice of medicine. Yet, as time passed, optometrists' philosophy has changed. They decided that they wanted the ophthalmologist's degree without the clinical education, medical school internship, and residency. In an editorial, a past president of the New Jersey Optometric Association referred to medical school as a myth: “You don't have to go to medical school to be a physician.”1 In New Jersey and other states, optometrists now advertise themselves as optometric physicians. What can we expect the public to think, when many graduates of medical schools do not know the difference between an optometrist and an ophthalmologist?

MANAGED CARE
How can ophthalmology have allowed the managed care industry to commit to the specious logic that optometrists are better gatekeepers for managed eye care because they are less expensive and know more about eye care than primary care physicians? This happened in part because ophthalmologists were busy with patients, and because most ophthalmologists and medical doctors have little or no training in business management, interpersonal relationships, or any other area needed to negotiate with a managed-care company, a lawyer, or a legislator. Optometry has reinforced the value of camping on the doorstep of decision makers. The statement, “the absent are always in the wrong,” applied in this case.

SCHOOLING
Admittance to medical school requires academic success. For applicants to be admitted to the top universities, they must function well in the academic setting.

Medical school teaches students how to be scientists, to think logically, and to make life-or-death decisions. These skills are not really necessary in order to interact with a politician or an insurance company. Future doctors' undergraduate classmates came to be the group that learned how to function in other areas, such as advertising, marketing, fundraising, law, politics, government, and business. That is not to say that one is better than the other but simply to explain why “I just do not like politics” is often the mantra of the medical community. How do we explain to a scientist the logic of a legislator's behavior? How do we train our colleagues to recognize the body language that demonstrates the politicians' inner thoughts and sometimes predicts their ultimate behavior? How do we emphasize the whole issue to fellow ophthalmologists? How do we convince a politician that an argument is logical or even morally correct? How do we convince ophthalmologists that learning these valuable lessons will allow scientists to reap tremendous professional benefits?

The politicians want to know that you are there when they need you. Either you are there with a wheelbarrow full of votes or full of money. The legislator is less concerned about votes and money if a relationship has been forged between you.

POLITICAL FUNDING
Why are ophthalmology's PAC contributions relatively underfunded? The New Jersey experience provides an explanation. The New Jersey Optometric Association used to have a very sophisticated Web site (now it is only accessible by members) with extensive information readily available, such as ophthalmology malpractice settlements or the listing of all contributors to the New Jersey Academy of Ophthalmology PAC. Now, PAC contributions are a matter of public record, but it is surprising that New Jersey optometrists find it valuable to post this information for their members. The message is quite simple: here is a list of ophthalmologists who are contributing against us, thus supporting legislation that injures optometry, its scope of practice, and its income. Because this message is not written anywhere, its meaning becomes a matter of speculation or paranoia, but what other informative purpose could this material supply?

TAKE-HOME MESSAGE
So, who wants to chance losing optometric referrals? Play it safe. Do not contribute, or run the risk. Would you ever call an optometrist to ask why he is supporting his organization's efforts? Why do you consider it acceptable to receive what we in New Jersey have come to refer to as “the phone call?” Here is my point. Oklahoma no longer appears to be an aberration; numerous states throughout the country have had surgical-scope bills, laser-scope bills, narcotics bills, and oral-scope bills. Optometry's threat of creating a “parallel profession” therefore needs to be taken very seriously. The take-home lesson is, the absent are in the wrong. If you are not involved in the political system, it is assumed that you do not care. Get involved with your state and national academies, or optometry will define ophthalmology.

Ralph Lanciano, Jr, DO, is Clinical Associate Professor at Scheie Institute, University of Pennsylvania, School of Medicine, Department of Ophthalmology, in Philadelphia. He is the past President of the New Jersey Academy of Ophthalmology. He may be reached at (856) 665-5533; rclanciano@comcast.net.