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Thread: The end of "refracting-MD's?"

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    The end of "refracting-MD's?"

    For some time now, I've been aware the phenomenon of "refracting-MD's," physcians trained in areas outside ophthalmology but basically practicing some form of optometry, and I've wondered both here and in my mind how they are legally and ethically permitted to practice in this capacity.

    At least in Ontario, the registration of each physician contains the "Dr. X may practise only in the areas of medicine in which Dr. X's educated and experienced" condition on their licence. Comprehensive eye care is typically an area that that physicians are not educated in unless they complete an ophthal residency. While physicians are usually thought of as having an unlimited medical licsence, there are legal, ethical and practical limits to what each doctor does in their practice.

    Now, after a google search on the term "refracting-MD, I found this "refracting-MD" and this from the CPSO:
    Current Referral Details: Allegations of Dr. Franklin's professional misconduct and incompetence have
    been referred to the Discipline Committee of the College. It is alleged that
    Dr. Franklin failed to meet the standard of the profession and is incompetent
    in his practice in performing eye examinations in the care of 28 patients.

    Thoughts?


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    Should have left him in, too many OMD's think they are no longer required to refract. Nice to think some MD's would be left that do.

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    Quote Originally Posted by chip anderson View Post
    Should have left him in, too many OMD's think they are no longer required to refract. Nice to think some MD's would be left that do.
    in Canada, there are only approx 15 residency positions/per year in ophthalmology. Most OMDs often shy away from general ophthalmology practice and seek sub-specialty training and practice-- glaucoma, neuro-ophthalmology, cornea, medical or surgical retina etc etc.

    This has left primary eye care largely in the hands of optometrists, and in a very minor way family docs.

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    What about the General Practitioner MD's that are refracting in Ontario...how do they get to do that? Do they take a refracting course?

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    Quote Originally Posted by mike.elmes View Post
    What about the General Practitioner MD's that are refracting in Ontario...how do they get to do that? Do they take a refracting course?
    Yes they take a refracting course. I believe that there's a grey area in the regulations that GP's are able to take advantage of.

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    Quote Originally Posted by Golfnorth View Post
    Yes they take a refracting course. I believe that there's a grey area in the regulations that GP's are able to take advantage of.
    Do you know what organization facilitates the course? Do they attend any other courses on eyecare or just refraction?

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    Quote Originally Posted by Oedema View Post
    Do you know what organization facilitates the course? Do they attend any other courses on eyecare or just refraction?
    Sorry Oedema I don't know any particulars.....just know that it must exist.

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    update

    http://www.cpso.on.ca/Doctor_Search/...14&iCPSO=23701
    On July 19, 2007, the Discipline Committee found Dr. Franklin to have committed
    an act of professional misconduct in that he failed to meet the standard of the
    profession.

    Penalty hearing dates: October 10-11, 2007.

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    I beleive in Dr. Franklin's case he was using only an autorefractor and not a phoropter to test eyes. At least that was what was told to me a few years back by a collegue. It may have nothing to do with the fact that he is an MD who refracts....just the fact that he was proved to have given poor care.

    Regards,
    Golfnorth

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    Correct, the issue facing Dr. Franklin is failure to comply with standards of the profession while caring for his patients. Whether he failed to do subjective refractions or tonometry or somthing else... I guess we'll find out when the college posts it summary online. My concern was never with the fact that this MD, and others, were doing refractions, but whether their exams comply with the minimum standard of care as established by ophthalmologists and optometrists.

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    Odd when so many opthalmologist seem to think that refraction isn't part of an eye exam any more. So unless he made separate charges for refraction, he should be O.K.

    Chip

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    Trivia.... What year did medicare decide refraction was a non-covered service?

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    What does medicare's opinion matter.

    Question: Just because Medicare doesn't compensate for this. Why should it no longer be included as part of a routine eye exam for non-medicare patients? After all it's why the patient came to see you.
    Unless the patient has been informed of some potential danger, family history or such. He goes to see the eye doctor to have his eyeglass prescription checked, period. The fact that the eye doctor is smarter than this and checks for physiological conditions is a good thing but it's not what motivated the patient.

    Chip

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    Quote Originally Posted by Golfnorth View Post
    I beleive in Dr. Franklin's case he was using only an autorefractor and not a phoropter to test eyes. At least that was what was told to me a few years back by a collegue. It may have nothing to do with the fact that he is an MD who refracts....just the fact that he was proved to have given poor care.

    Regards,
    Golfnorth
    This MD has a month to appeal, so I'll wait for a summary too. But when I was in retail, the majority of Rx redo's came from the OMD rather than the Optometrists. I wonder if anyone knows just how much actual refraction training OMD eye specialist surgeons receive?

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    Quote Originally Posted by tmorse View Post
    This MD has a month to appeal, so I'll wait for a summary too. But when I was in retail, the majority of Rx redo's came from the OMD rather than the Optometrists. I wonder if anyone knows just how much actual refraction training OMD eye specialist surgeons receive?
    i've worked in two large us universities with popular omd residencies for the past 10 years.

    in the usa, and i guess canada too, md's spend 3 years in residency specializing in the ophthalmology. the residents get lectures on refraction from attending omd's and OD's on staff. i'm sure they get tested on it every year in the (sp?) OPAK exams. However, the residents are also learning about diagnosing red eyes, treating systemic disease influences on the eye, microsurgery, etc. IMHO i'd say they spend <15% of their learning time on the trials and tribulations of refraction. By the time most of the patients get to an OMD, ideally, their refraction is not the problem. the onus is put on the resident to bone up on refraction and some do it better than others. if a resident is interested in becoming a retinologist, their focus isn't on refraction. if the the resident in aiming for cornea/refractive surgery/peds, refraction becomes a bigger part of their concentration, esp retinoscopy for peds OMD's.
    so in short, it really depends on the resident's gumption for refraction, their specialty, and how many good lectures they received on refraction during their residency.


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    Quote Originally Posted by itek2od View Post
    so in short, it really depends on the resident's gumption for refraction, their specialty, and how many good lectures they received on refraction during their residency.

    My experience is that it depends on if they have any vested interest in the refraction, i.e. do they dispense? A non-dispensing OMD or OD doesn't have to pay for the remake, so they don't focus on or excel in refractions. Also, if they don't dispense, they are probabaly seeing 40-60 pts/day. No time to check the autorefractor in that practice.
    It isn't very nice to say, I know. But it's my experience and the experience on many others on this board, I'm sure.

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    Quote Originally Posted by Oedema View Post
    Comprehensive eye care is typically an area that that physicians are not educated in unless they complete an ophthal residency.
    I think that's the point right there. Refracting MD's don't give a comprehensive eye exam. You go in, you get our RX, you leave. I also think that's where they can get away with it too. Most people don't know what's involved when it comes to a full exam, but when it comes to laws, it's up to the consumer to know what they're getting.

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    Quote Originally Posted by itek2od View Post
    i've worked in two large us universities with popular omd residencies for the past 10 years.

    in the usa, and i guess canada too, md's spend 3 years in residency specializing in the ophthalmology. the residents get lectures on refraction from attending omd's and OD's on staff. i'm sure they get tested on it every year in the (sp?) OPAK exams. However, the residents are also learning about diagnosing red eyes, treating systemic disease influences on the eye, microsurgery, etc. IMHO i'd say they spend <15% of their learning time on the trials and tribulations of refraction. By the time most of the patients get to an OMD, ideally, their refraction is not the problem. the onus is put on the resident to bone up on refraction and some do it better than others. if a resident is interested in becoming a retinologist, their focus isn't on refraction. if the the resident in aiming for cornea/refractive surgery/peds, refraction becomes a bigger part of their concentration, esp retinoscopy for peds OMD's.
    so in short, it really depends on the resident's gumption for refraction, their specialty, and how many good lectures they received on refraction during their residency.

    MANY THANKS FOR THE UPDATE. :cheers:

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    Quote Originally Posted by Oedema View Post
    For some time now, I've been aware the phenomenon of "refracting-MD's," physcians trained in areas outside ophthalmology but basically practicing some form of optometry, and I've wondered both here and in my mind how they are legally and ethically permitted to practice in this capacity.

    At least in Ontario, the registration of each physician contains the "Dr. X may practise only in the areas of medicine in which Dr. X's educated and experienced" condition on their licence. Comprehensive eye care is typically an area that that physicians are not educated in unless they complete an ophthal residency. While physicians are usually thought of as having an unlimited medical licsence, there are legal, ethical and practical limits to what each doctor does in their practice.

    Now, after a google search on the term "refracting-MD, I found this "refracting-MD" and this from the CPSO:


    Thoughts?
    Dear OEDEMA,

    Found this interesting site by accident.

    See CPSO revised charges : out went " Incomp". Problem was charges of insufficient charting of NEGATIVE findings in 26 pts. Am in good company with Toronto Leading Neuro-ophthalmologist who was fined $100,000 ,by our now defunct Medical Review Committee , which decided her notes were incomplete. Still after 35 y. of OHIP there is NO TEMPLATE. (Just like handing out parking tickets, an easy way of making money.) NO PATIENT WAS INJURED. NO DIAGNOSIS WAS MISSED. Problem was with one lady who was referred to OPHTHALMO.(FREE under OHIP) because of symptoms she said were Meniere's but went to Optom who charged her $40 for changing Reading Rx by -0.25 & suggested she complain about me to our College. Other was SECOND OPINION from pt with early cataract, who had seen local Optom., & who I referred to Teaching hosp (where she was going for N/Surgical opinion re post car accident) for Stratus OCT (NOT COVERED by OHIP) in the EYE DEPT. She objected to having paid me $60 as she said I did not improve on the OPTOM's Rx.

    BTW was first in Ont. in late 1970s to use HUMPHREY AUTO-REFRACTOR + trial lenses + auto-lensometer (with UV detection) + Mentor Biomicroscope + Humphrey Visual field. Difference of opinion with Ophthalmo. peer reviewer as to use of TONOPEN with mini-latex condom on SCLERA avoiding X-infection, local anaesthetic(according to ALLERGAN unknown danger to foetus), & CORNEAL DAMAGE. (Now DIATON through-the-lid-tonometry approved by USA F & D. & on sale in Canada for $2,800. See Google DIATON).Also Retinal camera will make handwritten diagrams obsolete.

    MAIN POINT: 30 years REFRACTION with NO MISSED DIAGNOSES and NO MEDICO-LEGAL CASES.

    President BUSH's excellent decision on electronic records will no doubt be copied by Canuck authorities and so solve the Chart problem for ever.

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    Scandimed,

    could you please edit your post so it is a little clearer as to what you're trying to say? Are you saying that you are a physician?

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    Refracting MD

    Am MD with 20y+ experience in GP + UK Dip. Musculoskeletal diseases (incl. Rheumatoid dis & eye involvement) + U.Tor Dips. in Public Health & Industrial Health.

    Peer Assessor Kitchener Ophth. Dr. KISKIS wanted more negative findings in chart + wanted IOP readings on ALL pts over 40 y unless they object.
    Not in Official Guidelines. Disliked scleral tonometry. with Tonopen. (Avoids use of Local anaesthetic) LA Ophtho.Dr.WALLACE, inventor of TONOPEN has patent for new Tonopen to read IOP from scleral readings.(Coming to market in a few years according to personal communication with Dr.Wallace)

    Use Advanced Humphrey-Zeiss autorefractor with glare/low contrast testing + RAYNER lenses+Plus German OCULUS cleanable Trial Frame.

    Worked mainly in places where there was shortage of refractors. Not in Centre of Urban Cities.

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    In my experiences around the Baltimore, MD area. Most of the larger OMD practices have OMP doing the refraction as well as just about everything else. (checking angles, applying drops, tonometry, visal fields, retinal photos, biometry, and surgical assisting). These OMP are often involved with the bulk of the exam with the doctor lookign over the resutls to various tests and diagnosing. At most the OMD may check the refraction.

    We often see from certain offices axis readings n 5o increments even in patients with large amounts of cylinder, after seeing many Rx's from certain offices you get a feel for who's refining the Rx's and who's not.
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    Omp

    Who are OMPs.

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    Why Ophthalmic Medical Practioners Or perhaps Ophthalmic Medical Police?

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    Quote Originally Posted by Scandiamed View Post
    Peer Assessor Kitchener Ophth. Dr. KISKIS wanted more negative findings in chart + wanted IOP readings on ALL pts over 40 y unless they object.
    Not in Official Guidelines. Disliked scleral tonometry. with Tonopen. (Avoids use of Local anaesthetic) LA Ophtho.Dr.WALLACE, inventor of TONOPEN has patent for new Tonopen to read IOP from scleral readings.
    What's the rationale for scleral Tonopen? Numerous papers completely dismiss the reliability and clinical usefulness of scleral readings using the original tonopen. If you're concerned about risk to fetus from the anesthetic then consider digital punctal occlusion for 3minutes.

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