Zack Oakey, MD, is an ophthalmology resident at the University of California, Irvine.

Zack Oakey, MD

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 Welcome to “Eye Catching: Let's Chat,” 

 featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by 

 an ophthalmology resident at the University of California, Irvine.

 The views expressed in these blogs are those of their respective contributors and do not represent the views of 

	The below is Part II of my discussion of the scope of practice for optometry in California. Here I provide re-assessments of

 Please see my writing there for context.

	A couple things need to be stated openly. I am a first-year resident in 

 training, and as my Ophthalmology Knowledge Assessment Program score attests, I have been wrong more than I have been right. I have limited knowledge and experience as an MD in general, and ophthalmology resident in particular. Nothing in my writings reflects anything that was specifically taught while in residency or medical school. 

Why I don't support ODs' 'encroachment' on medical procedures

	This is my own way of thinking out loud, of testing the waters for ideas that may seem at first strange or out of touch. I want people to consider the foundational claims of their ideology and possibly resolve or at least consider conflicts that they hadn’t noticed. And, of course, I am my own audience. The ultimate goal here is to produce a sophistication that cannot be, as my favorite screenwriter David Simon has said, “summarized in a paragraph.

	We can and ought to entertain thoughts without necessarily accepting them. 

	Since I wrote Part I, I have received some significant attention from both sides of this debate. A recurring theme is emerging that I’d like my reader to consider. In my first post, I emphasized a concept of ethics we were taught in medical school to hold dear: patient autonomy. More and more, however, I am realizing autonomy must be balanced with other promises we have made, prominently among them is the more ancient (and stemming from another ethics concept, nonmaleficence): first do no harm.

	Given the circumstances, the harm that can come from emphasizing one part of this do-no-harm/autonomy two-sided coin without considering the other-and not striking a balance-cannot be understated.

	I now realize that I have committed that sin of understatement. Some of the details relating to the harm that can come from allowing optometry into surgical/ophthalmic practice are striking to say the least. A poignant example is an experience in Northern California where patients were under the supervision of an optometry department and their visual decline due to glaucoma was simply observed. Nothing was done for them, and no referrals were made to ophthalmology.

	Apparently, this is not an isolated incident. More than a few experiences have been reported in which patients thought they were receiving the standard of care under optometry, but they were not and the consequences were dangerous. I have been inundated with examples and it’s frankly shocking. 

Next: ODs' efforts are 'better described as a wolf in sheep’s clothing'

	While I stand by the economic and philosophical arguments I made regarding monopolies and the need to meet ideas with evidence in general, I have become convinced that I did not state one point clearly enough: what constitutes “safety” (as outlined in the message from the American Academy of Ophthalmology that triggered my prior blog) is not something a patient can be reasonably expected to know, making the need for strict certification and training criteria far overriding. 

	When I wrote, “those who can go to the MD will receive superior quality,” I wasn’t simply saying ophthalmology training demands more procedures and therefore is generically ‘better.’ I was implying that surgical skills, as a general concept, are informed by many hundreds of different experiences that reinforce and overlap others. Doing five or ten of a selected few is probably meaningless. I can’t see how anyone could reasonably argue with that. Any politician, medical professional, or thinker who believes they are not putting patients in jeopardy by letting optometrists perform surgery with training as outlined in SB 622 is almost certainly wrong. 

	But more important to me, and more fundamentally, I look at my initial gut reaction toward the bill as an exercise in understanding the tensions that exist in medical ethics. I’ve therefore come to the realization as a medical doctor that in this case, the oath to not harm a patient should be paramount.

	First do no harm makes SB 622 a bad idea that no one should support.

	Despite my original suggestion otherwise, I cannot in good conscience support the bill and I don’t support optometry’s encroachment into unchartered territory. Their efforts are probably better described as a wolf in sheep’s clothing.

Office-based surgery is coming sooner than you think

	No more now than ever have I realized that there isn’t a strong enough distinction between ophthalmologists and optometrists as it is understood in the general population. Friends and family within my own circle have regularly made comments and had experiences where it became obvious that they wished they would have known the difference. Yet we ophthalmologists have struggled to come up with a way to inform the public. The AAO’s logo contains the tagline The Eye MD Association, and we as ophthalmologists try to educate patients, but it just doesn’t stick. Direct education just isn’t enough.

	When I read SB 622 initially, I wondered what kind of impact it would have on making this distinction. It actually seemed like a strong way of showing how valuable ophthalmology training is. Confused?

Next: The average patient still doesn't know who we are

	Ultimately, I want more of the correct patients to come to ophthalmology settings because we are the only providers qualified to perform certain tasks. As I said before, the bill “may lead to an increase in patient demand for MD-based care.” My reasoning followed the autonomy pathway: the patient has ultimate control over his/her body and they may eventually see the benefit of having a trained surgeon give them what they seek when they find that under-educated practitioners don’t produce the same outcomes. More importantly, the political machine, which responds to popular opinion, would recognize that the people want care that is commensurate with the required level of instruction on the basis of this predicted poor outcome. 

	The current approach is simply to write into law that those who can perform a procedure safely ought to be the only ones to perform it. As we’re finding out, that strategy seems to work only so well.

	The law can be as fluid as popular opinion. The scope of practice question is something that is continually open for discussion and we don’t have the general population, but in particular its elected representatives, behind us.

	It could be because the average person still doesn’t know who we are. Their tongues twist when they say “othmalolology.” When we say “eye surgeon,” things get a bit clearer, but not still clear enough. In one poll, more than 90% of respondents claimed they knew the differences between both professionals, but only a small group could actually define those differences.

	To solve this issue, we could go down the same road: ask elected representatives to listen to our small voice and we could continue to warn about potential patient morbidity. We could continue to inform patients, one at a time. We could pass out fliers, place television ads, tattoo “eye surgeon” on our foreheads, or screen-print pictures of eyeballs on our scrubs. 

	Yet, in 34 states optometrists can prescribe glucocorticoids. They can perform some form of an injection in 15 states, and in three states they can perform laser procedures. At least four states allow lid lesion removal.

Next: We only need certified, qualified practitioners

	The fact that California is the next state in the cross hairs, and that optometry associations are proposing to make further ground by adding eyelid procedures in more states, should tell us how powerful our methods have been to date.

	In my last piece, I proposed one way to address this issue-show the broader community of patients the results of their misunderstanding and apathy by allowing lesser-qualified providers to demonstrate that ophthalmologists were probably correct. As I wrote before, “maybe our patients and our colleagues in medical practices, both of whom equivocate on the term ‘eye doctor,’ will take the value of our certification more seriously.” We can get help without asking for it and accomplish our task without lobbying if there were a broader, culturally secured understanding.

	Of course, the fact that patients would likely be harmed in the process would be what Lenin might have called “breaking eggs to make an omelet.” The ultimate value might be long-term safety at the expense of short-term danger, an investment whose fruits would be social/cultural understanding that wouldn’t require any MD or government to define our roles. The people would learn what we hope spontaneously. 

	Now that I’ve given it further thought and taken in additional input, I realize that approach could never be consistent with our ethical obligations. It clearly violates the promise to first do no harm. Or put in Machiavellian terms, the ends here do not justify the means.

	Simply stated, SB 622 is a bad idea that can’t pass ethical muster and could jeopardize patients’ health. We need a better, balanced solution.

	The list of things that could go wrong in any surgery is as long as medical school education-we need only certified, qualified practitioners. Our patients are more important than that and deserve no loss.

	To that end, I would encourage any willing reader to contribute to the Surgical Scope Fund established by the advocacy wing of the AAO.

 I have made my own contact as a consequence of this experience. 

https://www.youtube.com/watch?v=nRt46W3k-qw

http://www.veteranstoday.com/2010/12/01/va-optometry-care-good-or-bad/

https://www.angieslist.com/articles/whats-difference-between-optometrists-and-ophthalmologists.htm

http://www.newgradoptometry.com/optometry-scope-of-practice-united-states/

http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160SB622

http://www.aao.org/advocacy/surgical-scope-fund/overview

Articles

In his latest blog, Zack Oakey, MD, writes why he now believes OD-performed procedures should not be legal.

OD-performed surgery unacceptable, dangerous

 Ophthalmology Times introduces “Eye Catching: Let's Chat,” a blog series featuring contributions from members of the ophthalmic community. These blogs will be an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Zack Oakey, MD, an ophthalmology resident at the University of California, Irvine. The viewpoints expressed in these blogs do not represent the viewpoints of Ophthalmology Times and UBM Advanstar.

 first came to my naïve self, I made the right decision to seek a relationship with my medical school’s department. I met a number of prominent ophthalmologists, and all of them imparted great advice on application, on why ophthalmology is a good discipline, etc.

One of my eventual mentors said something I still remember: “When interviewing, don’t ruffle feathers; ophthalmologists are careful people who don’t want controversy.”

Blog: Caught between a husband and a wife: A cautionary surgical tale

I now believe in this observation from my own interactions. I’ve found that many traditions and conservative ways of thinking are preserved in the subspecialty more so than other surgical subspecialties. Withholding the expression of deeper and controversial thoughts and management plans has served me well.

What’s more, we seem to be the only game in town where, for example, superior alternating hemiplegia is known by its eponym (Weber’s Syndrome)-sometimes to the derision of our neurology colleagues.

We are most likely to believe that burnout results from bureaucratic tasks

, arguably a conservative notion contrary to the progressive ideas surrounding electronic medical records. 

In my personal experience, I have heard and seen that we seem to be the last in adopting changes in medical documentation. I’ve been in clinics where the Haag-Streit slit lamp dates back to the 1960s and the whole clinic note is an alphabet soup of “PDR d/t NIDDMII,” etc.

 (R-KY) among my colleagues is probably tempered by the same force, which has produced the above oddities. Ophthalmologists, in my personal experiences, don’t approve of him mostly because of his rough history with the American Board of Ophthalmology (ABO), the only certification organization for ophthalmologists in the United States. 

 disagreed with the ABO’s 1992 decision to exempt pre-1992 certificate holders from the need to re-certify every 10 years. 

He felt it was an “injustice” and that “the establishment” needed to hear a “clear message” that they would lose members, and their dues, if they did not treat all of their members equally.

In case you missed it: Should doctors be allowed to Google their patients?

Sen. Paul established the National Board of Ophthalmology (NBO) as an alternative to allow agreeing ophthalmologists to send this “clear message” and to make what he felt is a more rational process for attestation.

This is not the first time a national, certifying organization has been confronted with organized opposition.

As recently as this year, the American Board of Internal Medicine (ABIM)-an organization that continues to certify about 200,000 physicians

-has received a great deal of push back from San Diego cardiologist, Paul Teirstein, MD. 

Met with the demands and inconsistencies of Maintenance of Certification (MOC), Dr. Teirstein contacted his group of interconnected cardiologists and asked his interventional cardiology fellows to organize a petition to change the way the certification process is mediated.

Among Dr. Teirstein’s complaints are the price of MOC, its clinical relevance, and the general manner in which the ABIM could not mount a sufficient response to what he saw as an obvious issue. 

In other forums, he points out the dearth of evidence supporting the measures in place to certify physicians and notes that there is a significant financial conflict of interest in maintaining the offices of certifying organizations.

Dr. Teirstein raised significant support, garnering more than 10,000 signatures within a short period and has started a conversation loud enough that the ABIM has responded.

Less than a month ago Richard Baron, MD, president of ABIM, contacted his diplomats to inform them they would make some changes to MOC and planned other unspecified changes. 

This was not satisfactory to Dr. Teirstein, who had already established and named himself president of the National Board of Physicians and Surgeons (NBPS). He has already implemented policies with NBPS and described in popular print the “Paulian” ethos of monopoly, freedom, etc.


What these California MDs did was undoubtedly bold and risky. Behind the scenes there was probably a significant degree of ugliness in the development of NBPS.

 But that probably doesn’t matter to cardiologists interested in reasonable MOC, since it would seem as though they are more interested in substance. 

Perhaps these behaviors are more typical of the personality selected in the cardiology subspecialty. I found in my year of medicine/medical school, that those destined for the cath lab were disproportionately self-governing and more interested in content. 

Given the cardiology/ABIM context, the ease with which physicians agreed and trusted one another, as well as their preference for substance, I find ophthalmology’s response to Sen. Paul’s efforts to establish a competing organization dissatisfying. 

The ABO has a clear advantage in offering the public a standardized approach, and any pre-existing monopoly tends to have a clean-shaven face and a more-polished reputation. 

Sen. Paul’s NBO was dysfunctional and poorly orchestrated. His family-mostly holders of a bachelors degree and sometimes unaware of their status in the organization-made up the board of directors. He wasn’t able to adequately represent or fully supply the criteria for his certification, and some have described the test as “open book.”

The NBO ultimately failed and was not recognized by any state organization, including Kentucky where certification is not required to practice ophthalmology. 


Why does this matter so much to ophthalmologists? Perhaps the NBO’s failure had a lot to do with the fact that Sen. Paul, who was an ABO member from 1995 until 2005, was an excellent surgeon according to his politically oppositely minded colleagues.

 I can’t imagine running a private practice and organizing something like a medical board. 

What I mostly object to is the tones in which Sen. Paul’s efforts are addressed.

I dislike that cardiologists are able to recognize a problem with their certification and organize around an obvious monopoly, whereas ophthalmologists fall apart like oil in water at the thought of contradicting the prevailing notion of established attestation. Intimated in our discussions around Rand Paul, is the idea that he was somehow less qualified or was liable to dodging certification.

The fact that he received ABO certification and that he and the ABO agreed, to some extent, that an ophthalmologist doesn’t even need MOC should be adequate reason to call that idea into question. 

Besides, have you ever interviewed at Duke? Sen. Paul was accepted to its medical school without a bachelor’s degree and he completed residency there.

Ignoring his political ideology for a moment, ask yourself: What kind of person, other than someone who is obviously gifted, would match at a top residency, start his own private practice, start his own certification organization, run and win a seat in the Senate, become a libertarian icon and the new face of the Republican Party, and also avoid ABO certification on the basis of ability?

If we value consistency and honesty, we ought to find a more parsimonious explanation for the NBO/Rand Paul situation. He is a person who is consistent in his political ideology and will implement its natural implications regarding monopoly in his chosen profession. I honestly see nothing wrong with his history at NBO.

Good for him if he can show the flaws of the ABO, perhaps mend its paths, and make it a more equitable organization by utilizing the only mechanism available to combat monopoly: competition.

1. Physician Lifestyle Report 2015, Medscape, WedMD LLC

http://www.medscape.com/features/slideshow/lifestyle/2015/public/overview

http://www.washingtonpost.com/politics/how-rand-paul-tried-to-lead-an-eye-doctors-rebellion/2015/02/01/010994da-9cd6-11e4-a7ee-526210d665b4_story.html

http://www.abim.org/pdf/data-candidates-certified/Number-Certified-Annually.pdf

http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/abim/moc-online-petition-swells-more-10000-signatures?page=full

http://www.medscape.com/viewarticle/837012

In his debut blog, Zack Oakey, MD, defends Sen. Rand Paul's actions against the American Board of Ophthalmology, and challenges his colleagues to do the same.

Zack Oakey, MD

Articles

OD-performed surgery unacceptable, dangerous

In defense of Sen. Rand Paul

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