So, in 1967 Dr. Borish, Alden N. Haffner, O.D., Ph.D., and six other optometrists met for three days at New Yorks LaGuardia Airport Marriott to discuss the situation. We decided the only way to compete was to break the drug barrier and start persuading [optometrists] not to refer so many people, Dr. Borish says.
Despite the fierce opposition from ophthalmology and even those optometrists who wanted the profession to remain drugless, optometry eventually broke the drug barrier in all 50 states and the District of Columbia (see O.D.s Prescriptive Authority, page 40). Today, O.D.s can treat ocular disease, perform minor surgical procedures, and comanage cataract and refractive surgery. In Oklahoma, optometrists can perform laser posterior capsulotomies.
 |
In a year when optometry has come under attack from organized ophthalmology over the right to perform surgical procedures, optometrists may be debating whether the profession has grown too much. On the one side are those O.D.s who feel that optometry should not seek further expansion in scope of practice. We should stop, do our business and quit trying to get more of someone elses turf, says optometrist John Chatelain, a private practitioner in Houston.
Others look at the profession as a work in progress. The innovations that are taking place technologically in laboratories and in clinics across the countryas a matter of fact, across the worldare so dramatic, that to limit anything that optometrists do is both foolish and mundane, Dr. Haffner says.
Breaking the Barrier
In the late 1960s, it was limited scope of practice and intensified competition from ophthalmology that had Drs. Borish, Haffner and others so worried about the future of the profession.
As cataract surgery became a simpler procedure, some 25 to 30% of the ophthalmologists were performing about 75 to 80% of the procedures.1 Fearing that they could not support their practices by providing other medical eye care alone, the remaining M.D.s. turned their sights back to refraction and materials. They even went as far as to recruit comedian Bob Hope to appear in posters urging the public to see a medical refractionist. And, they distributed advertisements that stated that ophthalmologists could do everything that optometrists could doand more.1
Also, patients who were referred to an M.D. for a medical eye problem were likely to remain in the M.D.s care after treatment and refer others there as well. No matter how cooperative the ophthalmologist is, as far as the patient is concerned, you have referred [him or her] to another level of expertise, Dr. Borish says.
Other changes were taking place, too. Even in 1967, it was apparent that insurance companies would play a major role in health care delivery.1 And, insurers would be unwilling to pay for a visit to an optometrist, only to have to pay a second fee when the optometrist referred the patient to an ophthalmologist for medical eye care.
The education system had already changed. Between 1901 and 1924, when the first optometry laws were passed, optometrists were required to have the equivalent of one or two years of college. By 1970, optometrists were required to attend a four-year college followed by a four-year optometry school.
You went from one to two years to seven to eight years in seven decades, while the responsibility [of O.D.s] had not changed one iota from 1901, says Dr. Haffner, who is president of State University of New York State College of Optometry.
Incidentally, the first optometry laws, which defined and limited the practice of refraction, also unified refraction and disease detection. The laws also required optometrists to examine patients for departures from the normal and to refer as necessary for medical care, says optometrist and attorney John Class, of the School of Optometry at the University of Alabama at Birmingham.2
Although breaking the drug barrier seemed the natural move, Dr. Borish and his colleagues expected severe oppositionboth from ophthalmology and optometry (especially from older optometrists.) In fact, that was why O.D.s initially chose to seek privileges to use only diagnostic agents.
Optometrists were traditionally a drugless profession, Dr. Borish says. They took great pride in it.
Critics were opposed for a more fundamental reason. In their minds, optometry was really applied physiologic optics, and [drug privileges] took it completely away from that, Dr. Borish says.
|
O.D.s Prescriptive Authority |
|
Type of Drug No. of States* Source: American Optometric Association |
Now Dr. Borish, too, worries that the profession has shifted its emphasis too much to treating ocular disease at the expense of refraction. When optometry was a drugless profession, optometrists still dominated the refractive field. O.D.s had the cutting edge when it came to analyzing accommodative and vergence problems, treating anisometropia and prescribing prisms. These are the things that are suffering, Dr. Borish says.
The reason, he says, is that as optometrists scope of practice expanded, it became necessary to introduce more tests and procedures into the exam. To do these and still incorporate all the traditional aspects of optometry would be too expensive and time consuming.
Filling the Vacuum
To understand Dr. Borishs concerns, one must look at how the profession of optometry came into being.
Ophthalmologists, who themselves started to become a specialty profession in the mid-1800s, historically had been trained to treat ocular disease and irritation, but they had no training in the physiology of vision.
In the mid-1800s, however, ophthalmologists Hermann von Helmholtz and several of his colleagues began to describe that physiology, including accommodation and convergence, and the use of convex lenses to improve the eyesight of older patients.
Ophthalmologist Thomas Hall Shastid, who was handicapped by uncorrected refractive error until fit with spectacles, encouraged the medical profession to fit spectacles and eyeglasses.1 However, the medical profession considered the use of lenses to improve vision, other than in older patients, quackery. George M. Gould, a well-known ophthalmologist and editor of the journal American Medicine, also encouraged ophthalmology to take refraction out of the hands of oculists.
Meanwhile, optical businesses started operating in jewelry stores (frames were made of silver and gold, falling under the jewelers purview). Then, optician Charles Prentice, who trained as an engineer and studied optics, began doing his own refractionsand charging for them. Despite accusations from ophthalmologists that he was practicing medicine without a license, he rallied others. Through their legislative attempts, the first optometry laws were passed.
Ophthalmology left a vacuum in the field of refraction, and we filled it, Dr. Borish says. And if we leave that same vacuum as were tending to do, someone else is going to fill it.
Indeed, serious political consideration is being given to independent subjective refraction by opticians in British Columbia. So far, no legislative efforts to allow opticians (or others) to perform independent subjective refraction has been successful in the United States, although organized optometry remains on the lookout for legislative efforts.2
Nothing Left Behind
Other optometrists disagree with Dr. Borish and are adamant that expanded scope of practice does not mean that optometry is abandoning its roots, splitting into two separate professions (medical eye care vs. refraction) or abandoning such ancillary services as vision therapy or low vision.
As a profession, we are not leaving behind or forgetting ANY aspect of optometry, says Birmingham, Ala., optometrist Tommy Crooks, vice president of the American Optometric Association.
Rather, optometrists are trained to provide primary care in which a patient presents for a comprehensive eye exam, and the O.D. provides appropriate treatment and triage. Primary care can be different depending on skill level. But it is not coming in and doing a slit lamp [exam] and ophthalmoscopy but not doing a refraction, says Karla Zadnik, O.D., Ph.D., a professor at Ohio State University College of Optometry and associate dean for research and graduate studies.
OSU, she adds, requires third- and fourth-year students to complete courses in binocular vision, vision therapy, low vision and gerontology as well as disease management. The college also has subspecialty clinics in all these areas through which students rotate.
Dr. Haffner points out that residency education has continued to grow nationwide, with an estimated 250 residency program slots across the country. SUNY took the position five years ago that the individual who successfully completes an accredited residency program and is carefully evaluated at the start of that program has advanced clinical competence in the area in which the residency is devoted.
As optometry continues to advance, its logical that practitioners will choose specific areas of interest. Says Dr. Crooks: Do we have individuals within optometry who choose to specialize in one or more areas of practice and, at the same time, choose not to practice in certain areas of less interest to them? Yes. As a profession, have we identified and chosen to elevate one area at the expense of another? No.
James E. Sheedy, O.D., Ph.D., also of Ohio State University College of Optometry, agrees. Any fragmentation that I see within optometry is primarily due to the need for specialization, because it is becoming increasingly difficult for optometrists to be at the cutting edge in all aspects of eye care.
Something Special
This was the thinking when the AOA proposed a process of board certification and established the American Board of Optometric Practitioners, or ABOP. The idea behind board certification was to provide measures for expertise, education and training. But members of the profession rejected the idea, and in June 2000, the AOA House of Delegates voted to stop implementation of the board certification process and provide no new funding for ABOP.
Former AOA President John McCall, of Crockett, Texas, still believes board certification is necessary. We should have general certification, like family practice, and then under that, the natural place to go would be specialization and board certification, he says.
Although the profession hasnt formally recognized the need for specialization, it has been happening informally. All one needs to do is look at the optometric specialty societies that have been established, such as the Optometric Glaucoma Society (OGS) in December 2002; the Optometric Retina Society in 2003; and the Optometric Council on Refractive Technology in 2004. These societies join such existing organizations as Optometric Extension Program (OEP) Foundation, College of Optometrists in Vision Development (COVD) and the individual AOA sections.
To me, it is more of a maturation of the profession as a whole rather than some planned shift in direction toward new areas of responsibility at the cost of old areas of responsibility, Dr. Crooks says.
Toward 2020
But is there a point at which one says the profession has fully matured? Thats one issue the AOA plans to address at its Optometry 2020 Summits.
When he was inaugurated as AOA president, optometrist Wesley Pitman announced a new committee to plan Optometrys Summit: Tomorrows Vision, to discuss the future, well-being and education of optometry. Areas of discussion will likely include legislative challenges and agendas, economic trends, and the optometric physician model, just to name a few. The agendas will also include discussion of specialization within optometry, Dr. Crooks says.
The first summit, which will include representatives from various organizations, is planned for August 11 to 14 in Dallas. Basically, what we hope to accomplish at the first summit is to throw out on the table all of the different possibilities of what the practice of optometry might look like in the year 2020, Dr. Crooks says.
The second summit, expected to take place six months later, will look at the information from the first summit and try to determine exactly what we want the profession to look like in 2020, Dr. Crooks says. The third summit, six months later, will provide a final blueprint of what the profession should look like and offer a plan of how to accomplish that.
Economics, Demographics
For now, there are economic and demographic realities to consider. The economic reality is that only about 10% of patients come in for medical eye care, according to optometrist Irving Bennett, who consults with the AOAs Data and Information Committee. (Patients who need medical eye care come for repeated visits, so it is necessary to talk about numbers of patients instead of how often patients visit the office.) That means that nine out of 10 patients who present to the average optometric practice do so to satisfy their vision needs.
Indeed, Dr. Chatelain estimates that 98% of his practice is devoted to glasses and contact lenses.
But, the national average does not tell the entire story. Depending upon the demographics and the population served, there are practices that have very large numbers of high-risk medical patients, Dr. Crooks says.
For example, Richard Hom, O.D., took over two of the ophthalmologist clinic days at the San Mateo Medical Center in San Mateo County, Calif. The center serves a medically indigent population of 45,000. Dr. Hom says that primary-care physicians and certified diabetic educators routinely refer patients to him rather than an ophthalmologist. This significantly improves the value of the ophthalmology services [at the medical center], because they are concentrating on their most useful skill, which is surgery and advanced medical eye treatment, he says.
In some areas, an O.D.s training can make the difference in patients having access to eye care. For example, Dr. McCall has been on active medical staff of the local hospital, East Texas Medical Center, for 20 years. He has covered the emergency room because the closest ophthalmologist is 60 miles away.
Further, Dr. Crooks points out that the professional services portion of many practices are increasing due to several factors. These include expanded scope of practice and technological advances.
Perhaps the biggest change, however, is demographics, especially when you consider that we are part of an aging society. Theres going to be a big paradigm shift as we shift from emerging presbyopes to the presbyopes, to the 65-year-old emerging Medicare patient to the 85-year-old, Dr. Crooks says. They have different needs.
Some 38 years ago, optometrists, fearful for the future of their profession, decided it was necessary to seek expanded scope of practice. Today, some O.D.s worry that the profession has grown too far beyond its roots, de-emphasizing those elements that brought the profession into being. Others say continued expansion in scope of practice is logical and necessary.
Dr. Haffner sees two fundamental issues: One, are optometrists educated and trained sufficiently to be responsible for an area of clinical activity, or can they be educated and trained productively to serve the public? And the second issue: Is it in the public interest for optometrists to have an expanded role in eye care? The answer to both questions, he believes, is resoundingly yes. n
1. Borish IM. Optometry: Its heritage and its future. Indiana J Optom 2001 Fall;4(2):23-31.
2. Class JG. Will refraction by optometrists survive the 21st century? Presentation at the American Academy of Optometry Annual Meeting, December 2004.
