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  1. #1
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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
    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 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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    ATO Member HarryChiling's Avatar
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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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    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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    Scleral Tonometry

    Recent paper by U.Toronto Eye researcher showed that many Hospital GOLDMANN tonos were not calibrated for years and certainly not sterilized between patients as per Ont. Gov. Regs. DISPOSABLE tips available but rarely used in Toronto.

    Tonopen with Latex mini-condom avoids X-infection + scleral tonometry avoids any damage to cornea. Divide scleral readings by 2. Original tonometry was scleral by Dr.DONDERS. Have not missed Glaucoma in 50,000 pts.over 25y.

    After 50y., movement away from Goldmann to newer Tonometers. iCARE an example. Also through-the-lid DIATON tonometer USA approved @ $2,500. PROVIEW though-the-lid @ $100 useful for follow-up. China buying lots. Inventor Dr.B.FRESCO MSc OD FAAO in Toronto.

    Single IOP as valuable as non-fasting Blood sugar. Suggest Tonometry OK for follow-up but nowadays non-mydriatic fundus camera + Fast Vis. Field + OCT + HR3 gives precise diagnosis + hard copy.. Note Bascom Palmer charges $1,500 PER EYE for technical assessment.

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    There are no guarantees without a website, you will not capture any of those potential patients conducting online searches for eyecare-related products and services. To Find the best Best Eye Care Practice in USA you have to go for top searches in webs.
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    Do you mean this one?:
    http://www.cpso.on.ca/Doctor_Search/...09&iCPSO=56787

    What is disturbing is that with all the complaints early in his career as a resident in anesthesia the CPSO determined Dr. Im was too unprofessional to practice medicine and stripped his licence of all medical priveleges except for "refractive optometry" in an optical store - if there is such a specialty.
    So the CPSO deemed him not professional enough to be a medical doctor, but OK as a refracting MD.
    Then in 2004 he was arrested.

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    Appeal Denied, but...

    From CPSO: http://www.cpso.on.ca/docsearch/deta...=4&id=%2023701
    Appeal denied, but the suspension seems to have been eliminated leaving only a 1wk preceptorship and a couple of inspections.
    This case sets a precedent that refracting MD's are not subject to the same standards as eye doctors, only to the standards of a "general practioner limited to eye exams" - whatever that means. Specifically, in the decision it was decided that a dilated fundus exam is not a standard of care required by a GP. Essentially this sets up a lower standard of eye care permitted for refracting MD's.
    So if they miss an undiagnosed or symptomless retinal tear or disease - no liability. How does this help protect the public? Unfortunately, the John Q. often assumes the refracting MD is a optometrist.

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    North Star, I know exactly how you feel.

    There are receptionists, or "certified" optometry assistants who measure, fit, dispense, fill Rx's and counsel patients every day. They provide a different level of care than opticians, and John Q often assumes the assistant is an optician.
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    Nobody goes blind from a seg. ht. that is 1-2mm too high, but that is for another thread.

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    Master OptiBoarder Shwing's Avatar
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    back to the original discussion (sorta), here in Alberta, the government is considering de-insuring eye exams completely.

    They de-insured (this means: paid/ not for by the government) eye exams for those between the ages of 19 and 64 back in '94. .

    Anyway, the Ophthalmologists have been asking for de-insurance of eye exams for everyone all along- Why? because none of them are General Ophthalmologists- all 100 +/- in the province are sub-specialists, and so none are refracting, so why waste tax-payer $$ paying for eye exams no-one is doing?

    Except my guy, but he's old as PMMA...
    :-}
    Shwing

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    You mean optical stores don't hire "burger-flippers" to work the dispensary or just shift a salesperson over from the shoe department? A relative of mine worked their way through college dispensing eyewear at a prominent optical store in T.O., alone 75% of the time with only on-the-job training, to do everything from frame selection to grinding and pick ups. It wasn't until years later when I informed them that that was illegal and they realized they could have gotten in trouble.
    Anyway this is for another thread.
    Eye exams that don't provide standard of care ocular health testing has the potential for harm; dispensing eyewear with uncertified personel has the potential for eyestrain. IMO it is essential that dispensing be done by trained certified personel; if you have incompetent staff the real harm will be to your reputation and eventually your bottom line regardless if you are an optician or optometrist. Patients may be inconvenienced and frustrated, but unlike undetected, undiagnosed eye disease, there is no permanent damage to vision.

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    Quote Originally Posted by NorthStar View Post

    1. IMO it is essential that dispensing be done by trained certified personel; if you have incompetent staff the real harm will be to your reputation and eventually your bottom line regardless if you are an optician or optometrist.

    2. Patients may be inconvenienced and frustrated, but unlike undetected, undiagnosed eye disease, there is no permanent damage to vision.
    I agree with number #1.

    I beg to differ with number #2.

    In most cases, #1 goes undetected. However, suppose that patient from #1 falls down their stairs or crashes their car with their new bifocal lenses???

    Now you have a bigger, expensive problem and one that requires a lawyer. It is also one that is fully visible to the industry, your peers and the general public. That's alot to gamble on for saving a few bucks an hour.

    Meanwhile, Betsy is gone back to flippin burgers.

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    I don't think I'll ever get over how ridiculous that "Dr." Franklin is, the man's rationale for how he practiced.... SENILE?

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    His exaggerations on his credentials and views on IOP measurement even after the college decision (see Scandiamed's earlier posts on this thread; Scandiamed is Dr. Franklin himself) combined with complete arrogance yet all he received was basically a slap on the wrist. Perhaps because of his age the CPSO assumed he would just retire soon anyway.

    But the CPSO's attitude, as with this case and Dr. Im's, seems to allow medical doctors who are unfit to practice medicine are still OK to practice what they call "refractive optometry" (quote from the case of Dr. Im; whatever that means) in an optical store. And with Dr. Franklin's precedent-setting case, refractive MD's don't have to worry about performing a dilated fundus exam. Thus their refraction-oriented exams (or are they just sight tests?) remain quick to crank those refractions through.

    Looking at a back issue of Optical Prism January 2010: Dr. Franklin MD posted a classified ad selling his Mentor Slit-lamp, Tonopen and trial lenses.
    Last edited by NorthStar; 08-31-2010 at 07:15 PM.

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