In his latest blog, Zack Oakey, MD, writes why he now believes OD-performed procedures should not be legal.
Editor’s Note: Welcome to “Eye Catching: Let's Chat,” a blog series 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 Zack Oakey, MD, 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 Ophthalmology Times or UBM Advanstar.
The below is Part II of my discussion of the scope of practice for optometry in California. Here I provide re-assessments of the points from Part I. Please see my writing there for context.
A couple things need to be stated openly. I am a first-year resident in ophthalmology 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.
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.1”
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.2
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.
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.
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?
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.3
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.4
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.5
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.6 I have made my own contact as a consequence of this experience.