On the battlefield, the maneuver is called a diversionary assault. Thats when the enemy attacks your flank to divert away your attention and resources. Its designed to delay or prevent you from launching a major frontal assault against them.

Whether or not that was organized ophthalmologys intent in 2001, that was the net effect, most notably in comanagement battles in Florida and Missouri.

Theres a saying we have in Florida: When youre up to your [elbows] in alligators, you dont have time to drain the swamp, says Jim Stephens, O.D., legislative co-chairman for the Florida Optometric Association (FOA).

Without a doubt, putting us on the defensive is part of their strategy in order to keep us from introducing positive legislation, he says. In Missouri, the story was somewhat similar.

We were fighting [against] the comanagement bill, and we were fighting for the childrens eye exam bill, says Lee Ann Barrett, O.D., immediate past president of the Missouri Optometric Association. It was kind of hard to play offense on one issue and defense on another. (Although she doubts that it was a purposeful plan by ophthalmology, the MOA hadnt expected to fight two battles in one year.)

Now, ophthalmology has adopted a new tactic to limit optometrys scope of practiceusing the courts instead of working through the legislature. Optometrists in New York State have appealed a court ruling (initially sought by an ophthalmologist) that has taken away their ability to perform punctal occlusion and probing.

Ronald Foreman, O.D., immediate past president and legislative co-chairman of the FOA, puts into perspective what he thinks organized ophthalmology wants to do on a national scale.

I think they would like to take [away] further privileges, like they did in New York, he says.

If you think the single issue on their minds is comanagement, youre fooling yourselves. This is the beginning of a total dismantling of what weve gained over the last 20 years. He suggests that some ophthalmologists are joining forces with opticians to take away optometrists bread-and-butter: refraction.

The Low-Hanging Fruit
Over the past 20 years, optometrists have gained a lot of ground acting on the offensive. Just two decades ago, O.D.s in only two states could prescribe drugs to treat eye disease. Now, all 50 states have some form of prescriptive authority. Only five lack the ability to treat glaucoma.

Only in the past couple years has optometry been forced to adopt a defensive, rather than an offensive, strategy. In early 2000, the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS) issued a position paper that denounced comanagement of eye surgery patients.

Then in the early spring of 2001, ophthalmologists took it to a new front: the state legislatures. In Florida and Missouri, they got legislation introduced that would have barred O.D.s from comanagement, except in rare cases. Neither bill passed.

Optometry has done pretty well over the years, and I think they never realized that it was possible to lose some of the things that they have, says Dr. Stephens. They never thought that one day they could get out of bed and not be able to treat glaucoma, or do comanagement.

Success in expanding scope of practice comes in waves, explains Jerald Combs, O.D., chair of the AOAs state government relations center. For example, optometry passed a lot of legislation in the late 80s, then hit a dry spell in the first years of the 90s, he says. This is just another short dry spell before our next wave of successes in the cycle of optometrys legislative efforts.

I wouldnt say that ophthalmology is gaining ground, concurs Jan Dorman, executive director of the New York State Optometric Association.

The only difference now is that optometry has already picked the low-hanging fruit. The remaining few are harder to reach. Its akin to the law of diminishing returns. You can have so many winners in a row. Then you hit a point where the resistance is greater and you have to increase your force against that resistance, Mr. Dorman says.

But where is this increased resistance coming from? And why?

Organized Ophthalmology?
Above all, who is behind organized ophthalmology?

When youre speaking about organized ophthalmology, youre really speaking of the Academy [of Ophthalmology]not [individual] practicing ophthalmologists, explains Peter Kehoe, O.D., AOA board of trustee liaison to the AOAs advocacy center. As an organization, the AAO sometimes creates policy (such as its position paper with ASCRS) against optometry to effectively limit your scope of practice.

Yet, the vast majority of optometrists work with ophthalmic surgeons who believe that comanage-ment of care is often best for the patient, Dr. Kehoe says.

The Case for Supporting Your Legislator
To gain the support of legislators, you need to support them. For the most part, thats done by spending time. But it can also mean spending money.

We hear it a lot, that contributing to a campaign is buying votes. But in reality thats not true, says Peter Kehoe, O.D., AOA board of trustee liaison to the AOAs advocacy center. The contributions of time and money are really no more than to help [legislators] stay in office, get elected or get re-elected.

What really countshistorically as well as in the futureare the personal relationships that optometrists can forge with their elected officials, Dr. Kehoe says. And thats where optometrys strength lies.

Optometry has never outspent its opponents. Its outworked them. Its a grassroots organization that has succeeded due to these personal relationships, says Jerald Combs, O.D., chair of the AOAs state government relations center.

It takes every single optometrist to give either financial or general support to their legislators as well as to the association leadership so that as we move forward we speak as one voice, Dr. Kehoe says. And for over 30 years weve done a good job, and we need to continue that.

But optometrists have become complacent after legislation has gone their way. And, optometrists whove graduated into therapeutic privileges dont consider that those privileges can be withdrawn.

Optometrists have to realize that political action is part of their overhead, that they have to give money and be politically active in order just to stay where they are, says Jim Stephens, O.D., legislative co-chairman for the Florida Optometric Association.

How can you get involved? Heres what Drs. Kehoe and Combs suggest:

• First, contact your local or state optometric association (even if youre not a member) and find out what district youre in, who your representative and state senator are. (You may have different legislators at home and at the office. Ask for the names of all of them.) Ask what kind of relationships other colleagues have built with these legislators.
• Call the legislators office. Offer to help in any wayto work a phone bank, distribute fliers or lawn signs, or participate in a fund-raiser. Explain that you welcome any calls or questions the legislator might have about any health-care issue. There isnt a legislator out there who wont call you when you offer to help, Dr. Kehoe says.
• Learn what the hot topics are in your district. Your thoughts on health-care issues will be respected when you can also speak intelligently on other issues.

You know youve reached the point where youve got a good relationship with a legislator when he calls you and says, Theres a bill here on my desk What do you think about it? Dr. Kehoe explains. Thats the goal. J.M.

On a local level the relationship between optometry and most of ophthalmology is good, Dr. Stephens says. Indeed, in the battle over the comanagement bill in Florida, more than 250 ophthalmologists (better than half of all O.M.D.s in the state) came out and rallied with O.D.s against the bill.

Its not fair to say that [all] ophthalmologists are in favor of prohibitions on comanagement, Floridas Dr. Foreman says.

Certainly with the advent of refractive surgery, optometrists have developed even better relationships with ophthalmic surgeons, says David S. Davis, O.D., president of the Nevada Optometric Association. (Nevada ophthalmologists proposed an equitable, friendly comanagement bill last year, right at the time when the Florida and Missouri bills were threatening.)

Some O.D.s on the front lines perceive that its the non-surgical, primary care ophthalmologists who have taken up arms against optometrists.

How are these O.M.D.s able to exert such influence? Larger forces may be at play. Heres how some of the O.D.s on the front lines view the scenario: It used to be that state optometric associations went toe-to-toe with state ophthalmology societies on scope of practice issues. Now, state ophthalmology societies are being influenced by the American Academy of Ophthalmology, as well as by state medical associations. The AAO and state medical associations, in turn, are influenced by the national organization, the American Medical Association.

Why would the AMA get involved? Its no secret that the AMA is losing clout among M.D.s. Only one in four practicing physicians is a member. Thats below half of the membership percentage of a generation ago, a recent New York Times article reports. And among the AMAs current 290,000 members, a large number are students, residents and retirees.

The AMA and state medical associations may hope to build or at least retain flagging membership by supporting specialty societies, such as the AAOwhich has displayed its own agenda against optometrists.

[The AMAs] general policy right now is to fight any scope of practice for any profession, and optometry just happens to be one of those legislated professions that continually pushes the envelope for scope of practice, Dr. Kehoe says.

Were a good target, Mr. Dorman says. That just means weve been successful across the country. They wouldnt pick on losers. Theyre picking on winners.

Other non-physician providerssuch as psychologists, nurse practitioners and pharmacistshave also come under fire for trying to expand their scope. But medical organizations may make an example of optometry, which has a comparatively successful history of scope expansion. Maybe they feel that if they can hold optometry back, theyll keep the others from moving forward as well, Mr. Dorman says.

Florida, for example, has a large pool of potential adversaries. While Florida has just over 400 ophthalmologists, the state board of medicine says it has nearly 60,000 licensed practicing physicians (not to mention all the retired ones). This kind of influence helped garner support for the anti-comanagement bill last year.

A Cure for Fat Cat Syndrome
We suffered from the fat cat syndrome, Floridas Dr. Foreman explains. We were doing reasonably well in our practices, and treating our patients properly. So O.D.s became complacent and dropped their guard.

Florida optometrists almost had to learn the hard way the consequences of letting our guard down, he says. We cannot blame anybody else but ourselves for getting in that position.

But by introducing the comanagement bill, optometrists adversaries in Florida have made the mistake of waking them up, Dr. Foreman says. Theyve regenerated and rejuvenated us. Were so much better organized and funded now, its going to be very hard for them to take us on again.

Nevertheless, one threat the FOA is watching is the combined force of semi-practicing ophthalmologists and would-be refracting opticians. The association successfully defeated an opticians refracting bill before. That bill would have allowed opticians to refract specifically under the general supervision of an ophthalmologist, likely one who would reduce his privileges in anticipation of retirement. That ophthalmologist could have virtually an army of refracting opticians working under his supervision.

Thats like fighting two allied enemies on two fronts (also known as a pincer attack, double envelopment, or hammer and anvil, in the theater of combat). Its a pretty scary scenario, but it could occur, Dr. Foreman says.

If you consider that optometry is a legislated profession, then you should know that only the legislature decides what optometrists scope of practice can be.

Because we are a legislated profession, we dont really determine what we get to do. No state board [of optometry] gets to dictate what an optometrist can and cannot do, Dr. Foreman says. They can say how they do it, but they cant say what they do. Thats left to state legislators. And if we dont educate them, who will? (See The Case for Supporting Your Legislator, at right.)

State optometric associations are recognizing they need to wake up their members again, Mr. Dorman says. Optometrys strength has always been in its grassroots. In New York, Kentucky and Floridaand probably in your statethe state association puts on a traveling roadshow to visit optometry schools, local societies and large groups of practicing optometrists to wake up O.D.s and get them involved.

What do these involved optometrists do? In Florida, for example, Anytime theres any type of political rally or political fund-raiser, optometrys there, Dr. Stephens says. They have a seat at the table.

Adds Dr. Foreman: Theres a lot of strength in numbers. We have at least 30 to 40 optometrists in the Legislature every day for the last two weeks of the legislative session When were in the capitol, they know that were there. They know well that were constituents.

Optometrists need to keep up their grassroots support, just to retain the privileges they have. Even if were not going forward with new legislation, we need to be strong as a group, as an organization, so we can always safeguard our ability to give our patients really good care, Nevadas Dr. Davis says.

That will protect the flanks while the front line regroups to fight another day.