ODs' Legislative Expansion

Optometrists who now have the licensed right to perform laser eye surgery in Oklahoma may be able to perform the same procedure in any Department of Veteran Affairs (VA) hospital across the nation. A major problem associated with this ruling is that Oklahoma's optometrists' surgical privileges have set a national standard. Even though Oklahoma is the only state that authorizes optometric laser surgery, the VA may allow those optometrists credentialed in Oklahoma to perform surgery throughout the country, regardless of their lack of medical schooling and preparation. Our veterans fought under the flag of the US, not the flag of Oklahoma. Why should they all be subject to the legislative vagaries of that state?

POLITICAL CLOUT
The optometry lobby at the state level continues to have a greater political influence than ophthalmology, and the former has used its power in rural states (where optometrists outnumber ophthalmologists 3:1) to achieve surgical privileges, as in Oklahoma. Optometrists will continue to use their political prowess to their regulatory advantage. It is expected that they will approach legislators in other states with the scenario, “if we may perform surgery in the veterans' hospital in the VA system, we should be permitted to perform surgery in any state.”

Optometrists have had first-rate relationships with legislators for more than 50 years, and they have made significant contributions to legislators, thus making it difficult for legislators to refuse their requests. Legislators are passing optometric scope-of-practice expansion rulings with little understanding about what they are doing. Congresspersons do not have the time to gain a thorough understanding of each bill that crosses their desks, a situation leading them to trust the information provided by their political allies.

Doctors of medicine are governed by a natural law. It does not matter how much you plead, how big your donations are, or how much you argue on behalf of the patient; if you do not manage a disease correctly, or if the disease is overwhelming, the patient dies. You cannot dispute natural law. Legislators and attorneys are governed by compromise and the ability to cajole, and they are influenced by dollars. Natural law does not play a role in their decision-making. Wannabe surgeons should obtain the privilege to perform surgery through education, training, and supervision, not argument, coaxing, and financial influence.

EDUCATION
Complex surgical procedures, such as laser eye surgery, require a concentration of experience and high-quality supervision during surgical preparation, performance, and postoperative follow-up. Only by completing medical school, fellowship, and residency (coupled with observing and performing numerous laser eye surgeries) will one achieve the skills of a surgeon. Optometrists should not perform surgery unless they finish medical school and all related academic training (eg, internship, fellowship, residency, etc.).

Unlike optometrists, ophthalmologists have 8 years of medical education, including surgical skills training and education on incisions and subsequent tissue reactions. That learning is the foundation for understanding medicine. A 90-minute workshop on a specific surgical procedure without this medical education does not constitute adequate training to perform a surgical procedure in humans. Two days are not enough, and neither are 4 months. Being a surgeon requires knowledge and experience that are only achieved through 8 years of medical training. To shortcut that process puts patients at risk. Patients need to ask themselves, “Do I want someone performing the surgery who has the foundation of medical school, or do I want a 90-minute wonder?” Most patients do not know to ask this question, however, they assume someone in a white coat who calls himself “doctor” has medical school training. That is not always true.

Although optometrists have tremendously expanded their scope of practice via legislative fiat over the last 10 years, no change has been made to the length of schooling necessary to become an optometrist. In 1992 and 1998, some leaders in optometric education stated, “We are already stretched to our limits in providing education to our students,”1 and “Expanding the scope of practice means expanding the curriculum, which is already bulging at the seams.”2 Optometry is expanding its scope of practice into the management of disease and the surgical realm without expanding its time for education and training. Intuitively, this situation just does not make sense.

VA SYSTEM
What has not been clearly defined is what the VA system means by “supervision.” Ophthalmic organizations, such as the AAO, are waiting to see that term better delineated. It makes no sense for an ophthalmologist to observe an unqualified individual, such as an Oklahoma-licensed optometrist, perform a laser procedure for the first time in a state that itself does not permit such privileging. Would it not be fairer to the patient for the ophthalmologist, who has the time to supervise the procedure, to perform it himself?

There is no backlog of laser procedures in the VA system. The enormous backlog that exists is of refractions, optometry's niche. Why do they want to move into areas for which they lack the medical training and experience instead of addressing an area of great need for which they are qualified? It is my understanding that optometrists are trying to become ophthalmologists. If that is their goal, why don't they go to medical school? n

H. Dunbar Hoskins, Jr, MD, is AAO Executive Vice President. He may be reached at (415) 981-2020; dhoskins@aao.org.
1. Wall LL. What are the pros and cons of requiring postgraduate residency training as an entry level practice requirement? J Am Optom Assoc. 1992;63:783-786.
2. Bamber HM, Grenier EM, Harris MG. An evaluation of the US optometry school curricula. Optometric Education. 1998;23:41-47.