OD's getting it from all sides

[Joann Raytar]

I would like to hear folks' opinions on the current situation that the OD's are facing. I am hoping for some thoughtful responses and not typical knee-jerk reactions to talking about the other O's.

This first link leads to an article in the AAO's EyeNet magazine:

• Eye M.D.s and Optometrists: Patients See No Difference

"Do optometrists "know their place"? Do ophthalmologists? This harsh question is an intentionally confrontational alarm. Some of our colleagues have pushed the "snooze button." They have rolled over and turned their backs on patients and medical colleagues–by going beyond comanagement of refractive surgery and cataract patients."

The article goes on to say that an OD exam and an MD exam are not the same creatures, OD's may refer patients to the wrong specialists, OD's are practicing Ophthalmology and patients can't tell the difference between and OD and an MD and may be confused.

This second article appears to be an Optometric response to the first article. It is from Jobson's Review Of Optometry:

• Optometry Under Fire: Because the profession has gained so much, does organized medicine have optometry in its sights?

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

This actually sounds a bit like some Opticians do. The article basically talks a bit about Ophthalmology's attempt to control the scope of Optometric practice through the court systems instead of legislation, the organization of Ophthalmology versus actual working relationships with local MD's, the AMA's support of MD's and specific issues relating to legislation in Florida.

It sounds like Optometry has as many parties working against it as Opticianry does. I thought Optometry was a highly organized area of practice; why are OD's having such a hard time keeping the ground they've gained? I don't necessarilly agree with the MD's opinions of OD exams; what are your opinions?

Any thoughts on the two articles folks?

[Joann Raytar]

I've slept on this one and so far, this is what I think. As an optical professional I would rather see an OD for a refraction than an MD. If I had to go to an MD's office, I know I would be much more comfortable knowing an OD was doing a refraction more so than an Ophthalmic Tech or perhaps even the MD for that matter. Refracting is an OD's core scope of training. I think the issue of OD's sending folks on to the wrong specialist is a bit of a stretch, especially since they use a retina specialist in their example. Wouldn't a retina specialist know that their services weren't needed and not continue on to treat the wrong diagnosis? Are MD's saying that other MD's also don't know what they are doing? I think the article has been written with more than a little bias and less than enough fact. Without numbers to back up their accusations the article becomes little more than an attack on another O.

On the other hand Optometry today brings up minor surgical procedures being done by OD's. In the same light I think I would rather an MD complete even Outpatient surgery.

From an Opticianry standpoint, why would we support MD's more so than OD's. Refraction and spectacle/CL fitting go hand in hand. This is the relationship that should be being repaired. If an MD practice is doing X% lasik procedures a year, how does that benefit area opticians, an increase in plano sun sales? There is definitely a tear in OD/LO communication. I think both would benefit from repairing it but I am not sure if old grudges would allow for any form of symbiosis between the two.

[Laurie]

Hi Jo,

Good thread.

I don't think it is old grudges holding us back, it is the same story as it has always been...market share. These legislative debates are not personal attacks, but attempts for the groups to hold on to what they have, and to try to gain more. It is probably the same in all professions, not just the O's.

OD's don't want us to refract because they need the sale of the eyewear. We want to increase our scope to refract because we need access to Rx's, and we are really good at it which would benefit the client (less remakes)... BTW...Refracting for opticians is not my fight...my fight is mandatory AS in opticianry...However, I think the OD's exagerate how much medical knowlege goes into refracting. I can pick up changes in vision and refer the patient to an MD just as easily as anyone else. MD's don't want OD's to perform medical duties, because it cuts in to their area of specialty, and they argue that the OD's never went to medical school (a valid argument, if you ask me).

OD's have said that they get it ALL in school...refracting, dispensing eyewear, pathology, pharmacology, etc...How many hours of each specialty??? How much is appropriate??

Opticians still refract in most parts of Europe and maintain a referral system with MD's. I haven't heard of a patient dying yet.

I had the good fortune to meet and spend time with Dr. Irving Borish who was very instrumental in OD's getting pharmaceutical rights. He had alot of interesting stuff to say in regard to the likelihood of opticians refracting. He warned the OD's not to forget where their bread and butter is, and told them to look around at the opticianry schools. He said that if they look at the text books we are using, they would see that they are the same books they have used in optometry schools for years.

I think that we will all continue to evolve and improve our situations. At our college we teach many different facets (no pun intended!) of the eyecare business so that our graduates can find their niche.

Laurie

[Pete Hanlin]

I think the conclusion of Dr. Weingeist's article pretty much summed up his fears and gripes...

We cannot have it both ways. We can't complain about the expansion in the scope of optometric care yet allow optometrists in our own offices to practice ophthalmology.

The way I see it, MDs have been allowing technicians to practice Optometry in their offices for years, so why not be consistent and allow ODs to practice Ophthalmology?

It is very hard to take any "concern" for patient's "level of care" very seriously when it is expressed by an OD or MD. Why? Because I've been to too many of their continuing ed hours. The typical CE for a physician spends more time telling them how to bill more and get more for a service than on how to actually perform procedures or diagnose conditions (at least in the ones I've seen). Read their publications, and its more of the same.

The fact is, MDs are concerned about the glut of ODs out there and how they are starting to eat in to their scope of practice. What seems to really disturb this writer is that patients are basically unable to tell a difference between the quality of care an OD vs. a MD provides.

When I was covered by an HMO, I used to see a Physician's Assistant (I believe this is someone with some degree of training, but not an actual "doc") instead of the "real" doctor. In my opinion, I received better care from her than I have ever received from an MD. Why? She actually asked questions and LISTENED to symptoms, etc. What a concept.

In my opinion, you are likely to receive better care from your local OD than your MD. The OD is always "hyped up" anytime s/he sees something out of the ordinary, usually s/he has more time to spend investigating the problem, and you'll definitely be referred along if you have anything past their capabilities (due to the liability exposure).

[Texas Ranger]

For many years, Opticians were 'independent', and MD's felt like dispensing eyewear was 'unethical', right up until Medicare cut cataract surgical fees. MD's went in to dispensing, something they have very little knowledge about. I know that the 1-15 people a day that we referred for an eye exam, were no longer referred to MD practices that told folks that "you don't need to go back to Al for your glasses, we'll take care of you here...". So, having always dealt with MD rxs, when the Dr. did the exam themselves, I was pleasantly surprised at how much happier our clients were with their 'percieved care' with the ODs, and our paying for Dr. redo errors went from $1,500/month to $100/month. Now, some of those dispensing MD's rarely refract, we cringe when we see their rx's come in the door, and their techs mostly tell our clients how badly their glasses were made, when they have trouble adapting to a big rx change. So, I think MD's have dug a big hole for themselves, and the first thing to do when you're in a big hole is "stop digging".

[MVEYES]

I work with 3 MD's. They don't beleive in making minor changes for eyeglasses just for the sake of selling glasses. Not all MDs or Optometrist are bad refractionist but there are some who are not quite adept at listening to the patient. Not all Opticians can fit eyewear either. The problem is that people are different and have different needs and we all need to take time to listen. PS We also don't fit contacts with differing base curves on a patient to create a corneal surface needing no glasses or contacts.


Jerry

_____________________________
!sevitcepsreP tnereffiD evaH llA eW

[MVEYES]

Is there any foundation in scientific principle that a program of eye exercises will help with any disorder of the human optical system?


Jerry


___________________________
! sevitcepsreP tnereffiD evaH llA eW

[Alan W]

There is a whole school of optometry that believes in the improvement of the visual system through various forms of excercise of the optical mechanism as well asthe neursystem. It is calaled Optometric Extension Program.

In other news . . .
Just this morning I saw a segment on CNN covering a nerotherapist in Canada who is improving learning and some behavioral disorders as well as changing the measureable IQ using eye exercises, reading upside down material, etc.

[Johns]

I'm w/ Jo and most of the others. I highly reccomend OD's over MD's when it comes to eyecare. (Notice that I don't use the term "routine eyecare". What is routine mean; you can do it in your sleep ?) I do belive that OD's are the "gatekeepers" of eyecare, and I think they do a great job for the most part.

Most MD's in our area have 3 exams going on at a time, being done by techs, and they spend 5 minutes with the MD. If the the techs miss it, the MD probably as well.

Speaking of MD's...how many times has anyone gotten one-eyed Rx's from them, because they're afraid you'll try to sell the patient something they don't need ? Happens all the time here.

[Homer]

Put that in your search engine and see what you come up with.

The day that optometry started using and prescribing medication they became Physicians in a real sense. Removal of foreign bodies and the use of some laser technology only secured this position.

Optometry no longer deserves to have an autonomous licensing board.
They need to be licensed as other physicians and subject to the same rules, dumping all of the commercial protection / economic protectionism by which they have become fat.

The standard of care for optometry in TPA, DPA and Glaucoma treatment is Ophthalmology so why aren't they treated as Physician's Assistants or Optometric Physicians as they love to call themselves.

Optometry statutes in nearly all states carry more language about commercial / economic protectionism than they do public health, safety and welfare.

They are either physicians or cleverly disguised merchants - they can't have it both ways!

[Alan W]

How do you REALLY feel?

And, I quite agree! But, the protectionist regs aint goin away so fast. Unfortunately!

[MVEYES]

Maybe we Opticians could learn a lesson from the move Optometry has made into a medical environment. The last I heard a physcian had hospital privileges.
PS Did you ever consider that prescribing for the good of the patient might lead to only one lens?







Jerry

[Joann Raytar]

Originally posted by Homer
The day that optometry started using and prescribing medication they became Physicians in a real sense. Removal of foreign bodies and the use of some laser technology only secured this position ... they can't have it both ways!

I have to agree with you Homer. If OD's want to continue to preform procedures beyond refracting then they should view themselves and be viewed by others as physicians and undergo the same qualifying criteria. If OD's want to be considered to be more than the "Chiropractors" of the Optical world then they need to make this commitment. After reading the above articles, however; I don't believe MD's would be their biggest cheerleading squad.

[SCO2004]

As some may know, I am a current student at SCO, and I would like to throw my hat into the ring........

I would like to try and take this point by point, so if this post gets long I apologize in advance!

(1)"OD's don't want us to refract because they need the sale of the eyewear": Laurie
---I respectfully disagree with this statement Laurie. I have a high respect for opticians and the work they are capable of doing. However, the reasons behind not wanting opticians to refract are many, and more complicated than this simple statement. The human eye, as you are well aware I am sure, is a complex piece of human anatomy and physiology. More goes into a refraction than just "one or two", and more goes in than just the application of optics. As optometrists, we are taught more than just to go through the motion of a refraction. I cannot do justice to the amount of education we are given in a single reply to the newsgroup. Speaking for myself (who else would I be speaking for?), I do not wish opticians to refract simply because they are not educated on the intiricies and theories and methods behind the refraction.

(2)"OD's have said that they get it ALL in school...refracting, dispensing eyewear, pathology, pharmacology, etc...How many hours of each specialty??? How much is appropriate??

Opticians still refract in most parts of Europe and maintain a referral system with MD's. I haven't heard of a patient dying yet." Laurie
------Laurie, I assure you that we get all of these subjects covered ad nauseum in school, and as far as what is enough? That is not for me to decide, but I know that I am getting enough education based on the fact that I can show my proficiency in the miriad of optometric skills, techniques, theories, and pharmacology as set forth by the National Board exams we are required to take and pass. Past that, I can point to the fact that Optometrists on the whole are competent and successful in the diagnosis and treatment of conditions affecting the visual system.

As far as not having a patient die.....that is debatable. The patient will not die directly from not having a quality visaul health evaluation. But, what if the optician (who I will assume in Europe does not have an equivalent level of education as an OD) misses any one of a hundred different types of ocular tumors, or space occupying lesions in the orbit/cranium, or Glaucoma, Diabetic Retinopathy, hypertension, etc., etc........No patients die from a poor visual exam directly, but I am certain that many do not get the same quality refraction that I could give.

(3)"We want to increase our scope to refract because we need access to Rx's, and we are really good at it which would benefit the client (less remakes)": Laurie
-----Optometry received much of its prescriptive authority based on the fact that OD's outnumbered MD's, and were therefore the "gatekeepers" of eyecare (as previously named). We were able to show that we could better deliver appropriate diagnoses and treatment to the public than could MD's because ther was a need there. To many people were slipping through the cracks and not receiving the eyecare they needed. There is no void in service to the public regarding refraction alone. Therfore there is also no need for opticians to refract, as there are ample optometrists ready and fully educated to do so. There is no benefit to the patient, and it could be extremely detrimental to them.


(4)"Is there any foundation in scientific principle that a program of eye exercises will help with any disorder of the human optical system?" MVEYES
-----I believe you are referring to the field of Vision Therapy. Vision therapy has been shown to treat many malfunctions of the visual system, including accommodative infacility, convergence insuficiency, vergence infacility, and many other binocular and monocular visual conditions.


(5)"OD's want to be considered to be more than the "Chiropractors" of the Optical world then they need to make this commitment."
------Oh, but I have made a commitment. I am not a chiropracter of the optical world, striving to be something I am not. I will be an OPTOMETRIST. I am studying and working my butt off to become an OPTOMETRIST. I will be a dedicated and competent OPTOMETRIST. If I wanted to become an MD, I could have easily gotten in to medical school, and I would have prospered there, without a doubt. I chose optometry, or rather it chose me, and therefore I am extremely proud of my profession. I will help countless people in many different ways, and will protect their most precious sense. I would want to be nothing else.

[Joann Raytar]

Originally posted by SCO2004
(5)"OD's want to be considered to be more than the "Chiropractors" of the Optical world then they need to make this commitment."
------Oh, but I have made a commitment. I am not a chiropracter of the optical world, striving to be something I am not. I will be an OPTOMETRIST. I am studying and working my butt off to become an OPTOMETRIST. I will be a dedicated and competent OPTOMETRIST. If I wanted to become an MD, I could have easily gotten in to medical school, and I would have prospered there, without a doubt. I chose optometry, or rather it chose me, and therefore I am extremely proud of my profession. I will help countless people in many different ways, and will protect their most precious sense. I would want to be nothing else.

I will give you my reasoning behind my statement. I had a person call me today to find out if our Doc, an OD, would be willing to just fit her daughter for contacts as she had already had an exam recently. I asked the mother how long ago her daughter's last exam was and she replied two days ago. She had gone to an MD and later that same evening, after the exam, decided to look into contact lenses. The morning after the exam she called the child's doctor to find out how much a fitting would be and what would be involved. The fitting alone came to $140. This was on top of what she had paid for the exam the day before. Even my jaw dropped; $230 for an exam and spherical contact lens fitting not including lenses??? The child went in for a simple refraction and eye-health exam. There is no need for any kind of therapy due to any type of eye disorder other than mild myopia.

The question that came into my mind was; why would a parent take a child without any form of disorder other than myopia to an MD? The MD's have to be projecting some kind of image or perhaps advertising message that is clicking in folks minds. I guess my use of the Chiropractor example is what threw my statement off. How do you, as a future OD, view this example? How would you theoretically change this image in the public's eyes as well as in the eye's of MD's?

[NC-OD]

Well Damn,
SCO2004 took all my thunder away. Now what am I going to talk about?:)

It is my contention that general ophthalmologists are the most over-trained professionals in the world. There is absolutely no reason to go through 4 years of medical school, concentrating on general body pathology with 1 or 2 lectures on the eye. This is followed by an absoultely NON-EYE related general 1-yr internship......THEN they train for 3 or 4 years on the eye (With some specialist training a few more years..ie. glaucoma, vitreo-retinal etc.)

This is absolutely ridiculous. NO ophthalmologist that I know acts as a general family practitioner. They examine eyes and eyes ONLY. A General Ophthalmologist = A recently trained (within 10 yrs.) Optometrist - the surgery (which in most cases is minor). The difficult surgeries go the the fellowshiped trained specialist (ie. Strab surgery in not done by a general OMD usually). Podiatrist treat and do surgery on the foot w/o med school. Dentist work on teeth and do tooth surgery (and not surprisingly noone cares because they have no competition).

What the hell is my point here? I don't know, I lost it. I have a little 1 yr old yelling in my ear!!!


Oh yea, about opticians refracting. People who are against it use the patients health argument. If opticians refracted independently, Every commercial place will have a $15/exam refracting Optician instead of a $75 OD........I know I would if I owned the place. It makes economic sense. Many people, being as cheap as they are, would go for the $15 exam. I would have done it in my pre-OD days no doubt. After all I just needed some more contacts.

By not doing a full ocular exam (which is probably not done many times by some commercial OD's but that is a whole other story), there would be many patient with missed ocular pathology. AND there are ALOT of jack-up eyes. WAY more than I ever thought when I got in to this field......

Now all that said, I still think that if Opticinary really got organized, then you guy (gals) would have a chance. But as Pete has said, it is going to take formal education. It will be much harder to put down opticianary if you'all could show that "we are trained in this, and this, and this just like the other O's and therefore we can and should be refracting.

NOW how your going to get both Optometry AND Ophthalmology to stand aside and give away refracting may be a miracle.

:cheers:

[Johns]

Great thread !

Sco2004:

I support OD's in most aspects, and do believe they are the gatekeepers of eyecare, but Laurie did not suggest that opticians should be able to conduct comprehensive eye examinations, which would entail a complete eye health check. I always understood that the refraction part of the exam was for determining the refractive error of the eye. If the V/A of the patient could not be brought to 20/20, the patient would be refered.
People would still get complete examinations every few years, but if opticians refracted , OD's might be left out of the loop if the referal was to an MD.

I have a complete exam every 2 or 3 years, but my refraction is done by one of my employee opticians. I have all the confidence in the world that the refraction I get is as good or better than the OD whose Rx we fill all day . )

[NC-OD]

Hi Jo,

I find that many times a patient makes their way to an ophthalmologist office on a referral by their primary care physician or pediatrician.

Unfortunately, every once in a while I have a patient call or pop in and ask my receptionist if I am an "Op-thu-mol-a gst or just an Op-tum-a-trst. My doctor said I have sugar (diabetes) and I need to see a real eye doctor not just an Op-tum-a-trst." I usually just smile and tell them I would be happy to examine them and tell them if their diabetes is affect their eyes. I have a large diabetic population and unfortuantely diabetes is growing at an incredible rate. Sometimes they stay. Some times they insist on an OMD cause that's what their dr. said. I have no problem with that and usually refer them to a great ophthalmologist in the area. (Either way, no matter who they see, if they have mod to severe diabetic retinopathy they will be sent to our local retinologist who handles all these cases)

Unfortunately, there still exist a great bias from some M.D.'s ---usually the older (and more ignorant) ones. Luckily they are dying away.....but not fast enough.

But speaking of having people against you. Recently the "EyeMD" ASSociation put out a recommendation for parents to have their kids eyes examined by an Ophthalmogist (O.K), your family doctor, or pediatrician. They didn't even mention Optometrists as being qualified to exam a childs eyes. I guess the 100 years of experience in examining kids that optometry has in not enough.

:hammer:

[Joann Raytar]

Johns,

In the article the phrase "comprehensive eye examinations" is what appears to have the Ophthalmalogists in a buzz. I think it is very unlikely that OD's referring to the wrong source is a major issue. Most MD's are in group practices. You mean to tell me if an OD refers a patient to a retina specialist in that group, that MD is going to treat for the wrong diagnosis and not refer to one of his partners? Who is at fault in that case the OD or the MD? To me it sounds as if the mistake lies in the hands of the MD. I can't see any difference in between an OD and an MD's compreshensive exams other than the price and the fact that the actual OD does the exam and not a tech. (Sorry, to any ophthalmic techs out there. However, if I pay $100 or more for an exam it better be the doctor doing the exam.) In regards to co-management of Lasik patients, aren't OD's who refract and check eye-health everyday the better choice for preliminary care and post-op care anyway?

Opticians talk about doctors asking us not to charge for remakes once and awhile on OptiBoard; do OD's run up against the same types of roadblocks when referring out to MD's? Have you ever been given a hard time about sending a patient back to an MD for follow up?

My doctor said I have sugar (diabetes) and I need to see a real eye doctor not just an Op-tum-a-trst." I usually just smile and tell them I would be happy to examine them and tell them if their diabetes is affect their eyes.

We often have folks come in with that same situation. We also tell them that the Doctor would gladly take a look and make any recommendations if he finds a need.

[Johns]

NC-OD:

You know that the "non-mention" of optometry by the group is nothing more than the "good 'ol boy" MD network at its best.

Speaking of real doctors, I recently had a lady tell me that her daughter had to visit an "op ti shun" because her daughter was 16 now and should get all her female stuff" checked out.

Okay, back to the topic...

[Johns]

Jo,

I would prefer to have a comp. exam from an OD because that is what they do for a living. Their training focuses on examining the eye. Not surgery.

When patients ask me for the name of a local ophthalmologist, I always ask, "Oh, do you need a surgeon ?" And then they usually go on about how they need a thorough exam, or that they have "sugar". When I explain the differences between the three O's (of course I am always careful to explain that they will die if anyone other than an optician makes and dispenses their glasses ;) ) they usually are grateful that the OD will be able to take care of them, and for a fraction of the cost.

[MVEYES]

Optometry: If a patient walked into your office and went into shock or had a seizure due to a drug reaction you would be able to treat them immediately to save their life? Ophthalmology are Medical doctors first and then optical specialist through a residency program. This all sounds like smoke screens with dollar signs behind it. There are a great deal of competent optometrist who do a great exam but like any profession there are some who aren't truly qualified to deal with life threatening emergencies. Drugs have created a whole different ball game in a practice. Human beings react differently to them. My money lies with that professional who has spent 4 years of in medical school and 2 years internship in a hospital setting and then 2 or 3 years in residency. If they can't save your life in an emergency situation then who can? You seem to have hit a couple of points on the head:
1. Numbers do make it more available for the general public to find a refractionist/eyecare professional (thus gatekeeper). That doesn't gaurantee the highest quality in service. ie Complaints come to us from chain optical centers where the patient relates that they didn't feel they had a thorough exam.
2. Education and the realization of our abilities through education is the key to sucess in any profession.
3. Have you ever gone to the hospital and had an XRay? Did the Radiologist conduct the XRay? That technician that conducted the XRay procedure had a whole lot more responsibility to completeing his task and keeping you safe. Think what it takes to do the basic refraction.

I've read a lot of rhetoric putting down MD's and the movement against refracting opticians but like the other O's it is educational training that makes a good technician. Why hasn't any of you brought up the point about premade readers available at any discount store. There you have an individual who is self refracting.


Jerry

[Joann Raytar]

Originally posted by MVEYES
I've read a lot of rhetoric putting down MD's and the movement against refracting opticians but like the other O's it is educational training that makes a good technician. Why hasn't any of you brought up the point about premade readers available at any discount store. There you have an individual who is self refracting.

I am not so much putting down MD's as pointing out that their argument in the above article is flawed. Most folks who go to an MD's office for general work ups are not being treated by the doctors themselves but by techs. So what if they are employed in an Ophthalmology practice? Using the logic that the author used in the above article, those patients would face the same risks in an MD's office as going to an OD because the MD's are not conducting the exam. Therefore, in my opinion, patients seeing OD's are being given equal if not more thorough exams.

My biggest pet peeve about readers is that they may keep some folks out of exam rooms for too long. Folks will purchase higher powers over time until the readers no longer do the trick; meanwhile, their eyehealth is being ignored. Companies that sell readers need to let their consumers know that regular esams are necessary. Even toothpaste manufacturers take that much responsibility by telling consumers to visit their dentists for regular check ups.

[NC-OD]

For what it's worth:

If a patient came into my office and had a seizure or went into shock (which has happened), I would do want any other doctor would do.....start immediate CPR, possible use epinepherine and CALL an ambulance. The dentist next door has an ambulance come to her office about once every couple of months. The Urgent Care across the street (staffed with an MD and an emergency room P.A.) calls the ambulance regularly. Last month when I was visiting a local Ophthalmology/Optometry referral center, they had to call an ambulance because an elderly pt. had a severe reaction to injected NaFl.

Despite what you see on t.v. Most doctors and doctors offices are not equipped to deal with life emergencies....Not even Ophthalmologists offices. I am certainly not bashing Ophthalmology. I worked with one particular OMD group very closely and they are great surgeons, average refractioninst (whoever is doing the refraction), and most important......good people.:)

[Laurie]

You were correct in what I wrote in my post.

Here in Florida there is actually the job title: Refractionist.

I never mentioned opticians refrating autonomous of a pathology check...

I can see several scenarios where the optician refracting with a close professional relationship with an ophthalmologist would certainly be in the patients' best interest.


Laurie