"Even though I love my optometrist, I would never, ever let him do surgery," says Denishia Martin Hostetler, an Angie's List member in Bowling Green, Ky., where lawmakers this year gave optometrists the right to perform some surgical procedures and expand scope of practice in other ways. "I would want a full-fledged MD, with lots of experience and credentials."
But Tom Wiesle, a member in Plano, Texas, expresses a less popular opinion in saying he'd feel comfortable going to his optometrist for laser surgery - if only his state allowed it. "I totally trust him," Wiesle says. "He's just so knowledgeable."
From California to Maine and 16 states in between, optometrists have been pushing to broaden services, exacerbating a turf war with ophthalmologists who provide the full spectrum of eye care. By being allowed to do more, optometrists insist they can help patients save money and benefit through improved continuity of care and fewer referrals to ophthalmologists, who are more expensive. "We're not holding ourselves up to be ophthalmologists," says Bill Reynolds, an optometrist in Richmond, Ky., and legislative chair for the Kentucky Optometric Association. But training and expertise have evolved, he argues, and practice needs to catch up.
Ophthalmologists fire back that optometrists - who attend a four-year post-graduate optometry program but lack their eight years of medical school, internship and residency training - are sidestepping critical experience and education. "They want to practice medicine without going to medical school," says Dr. Daniel Briceland, a highly rated ophthalmologist in Sun City, Ariz., and secretary for state affairs with the American Academy of Ophthalmology. "This is how people get hurt."
Intense optometrist lobbying over the last three years has produced mixed results. In eight states, they won approval to prescribe more drugs, administer additional types of injections like local anesthesia and - in the case of Kentucky - perform laser surgery. They failed to prevail in seven others, with lawmakers withdrawing proposals, killing bills on adjournment or stripping scope-of-practice provisions. Texas, South Carolina and Nebraska were still considering legislation at press time.
In West Virginia, the debate grew especially contentious as eye doctors on both sides of the issue testified at the state capitol in Charleston, with ophthalmologists sporting "Surgery by Surgeons" stickers and optometrists wearing "I Support Optometric Physicians" badges. West Virginia legislator Don Perdue thinks optometrists and ophthalmologists are sincerely concerned about what's best for patients, but add that both have professional clout and financial interests at stake as well - "money being of primary interest." Where scope of practice overlap, Perdue contends, they're vying for the same patients.
As chair for the state's House of Delegates Health and Human Resources Committee, Perdue became intimately acquainted with the two groups during a marathon negotiating session last year. "We spent those 16 hours locked in my office literally trying to keep people from clawing each others' eyeballs out," says Perdue, who ultimately voted with the majority to allow optometrists to prescribe more medications and administer some injections after laser surgery was taken off the table.
California legislators also rejected laser surgery but agreed to reduce training requirements for treating glaucoma, saying optometrists graduating after 2008 receive sufficient preparation in school. However, medical groups have sued to prohibit the new regulations from taking effect, saying optometrist education doesn't go far enough. "[The regulations] don't protect patients," says Dr. Craig H. Kliger, an ophthalmologist and executive vice president of the California Academy of Eye Physicians & Surgeons.
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Optometrists' move to deliver more of the care traditionally provided by ophthalmologists has helped to blur the line between the two professions. According to a recent online poll of Angie's List members, 93 percent claim to know the difference between optometrists and ophthalmologists, but 25 percent went on to incorrectly describe an optometrist as a medical doctor. "I thought they had to go to medical school," Hostetler says. "But they're referred to as doctors nonetheless. That's kind of a misnomer." Chuckling, she adds: "I have three master's degrees and I don't get to be a 'doctor.'"
Like Hostetler, most poll respondents have reservations about seeing an optometrist for anything but basic eye care. Just 8 percent would turn to one for help with glaucoma - which optometrists are permitted to treat in every state but Massachusetts. When it comes to injections and laser surgery, only 2 and 4 percent, respectively, say they would trust an optometrist.
Oklahoma became the first state to allow optometrists to perform some laser surgeries in 1998. That's also when lawmakers explicitly upheld their right to administer injections, remove eyelid lesions and prescribe an expanded list of medications. "The procedures we're doing are not technically involved," says David Cockrell, an optometrist in Stillwater and spokesman for the American Optometric Association. "We've never had a single case of a patient being harmed reported to the [state optometry] board. That's a pretty startling statistic."
It's also a misleading one, says ophthalmologist Dr. David Parke II, former head of the highly rated Dean McGee Eye Institute, based in Oklahoma City. "We had several patients come in with horrible complications from totally unnecessary surgical procedures," says Parke, now the executive vice president and CEO of the American Academy of Ophthalmology.
Pam Odum of Owasso, Okla., outside Tulsa, says she never would have gone to an optometrist for laser surgery had she known he was not a medical doctor. "I was almost blinded," says Odum, who sued Jan Jay Rigney for negligence and says his incompetence in performing a procedure to correct astigmatism and the homemade eye solution he gave her caused temporary blindness and permanent blind spots. "To this day, I have limited vision," Odum says. Rigney, who settled the case with Odum for an undisclosed sum, declined to comment.
Cockrell says if malpractice were a big issue, insurance rates for optometrists would have shot up in Oklahoma. Parke argues the reason they haven't is because optometrists are mostly still prescribing just glasses and contacts, which carry little risk. The potential danger to patients is very real, he adds.
Out of some 25 highly rated Oklahoma optometrists surveyed by Angie's List Magazine, only three say they perform PRK or another type of laser surgery. Although it's been more than a decade since the new law went into effect, most continue to refer patients to ophthalmologists at surgery centers who perform a high volume of procedures, including Lasik, which optometrists aren't permitted to handle.
Tami Ross, a highly rated optometrist in Oklahoma City, says she's certified to perform laser surgery but the investment in equipment isn't practical. "The lasers are pretty expensive," she says, estimating that PRK equipment costs as much as $500,000. "Unless you can pay for them doing [procedures on] a lot of folks, it's not worth having them."
However, Ross adds that many more optometrists in rural areas are performing surgery and she expects to see an increase in cities, too, because laser training's become the norm in optometry schools. "It's part of their curriculum now, so you're going to see more and more of that done than in the past," she says. "The new [optometrists] are taught it from day one."
Optometrists in neighboring Texas are among those seeking approval to perform laser surgery. If successful, optometrist Jeff Thomas says he might expand his services to include corrective surgery for certain cataract patients. The highly rated Dallas area optometrist - and Wiesle's provider - agrees with his peers that broadening care can reduce the need for referrals, save money and better serve patients. "That's the bottom line," he adds.
A household survey conducted by the Agency for Healthcare Research and Quality says patients spend about $50 on an eye exam out of pocket, whether they see an optometrist or ophthalmologist. But the total spent by all parties, including insurance, Medicare or Medicaid, is $132 for ophthalmologists compared to $94 for optometrists, says Jeff Rice, CEO and founder of Healthcare Blue Book, which analyzed more than 15,000 patient records. Similarly, he says, opening a blocked tear duct costs the system $169 for an optometrist versus $232 for an ophthalmologist.
"On average, it looks like ophthalmology gets paid about 40 percent more than optometry for the exact same services," Rice says. "I think it costs more because of the higher level of training and some of the additional overhead of a medical practice." Ophthalmologists also earn more than twice what optometrists make - $305,724 compared to $126,319, according to CareerBuilder.com.
In Texas, Thomas says he was taught how to use lasers and treat glaucoma when he went to the University of Houston College of Optometry in the 1990s, years before the state allowed optometrists to prescribe glaucoma medications. "They definitely train beyond the current scope of practice," he says.
Due to legal restrictions, students at the school gain experience by performing laser surgery on animals, primarily rabbits, says Earl Smith, the school's current dean. "About a quarter of our class rotate through Oklahoma and get experience on humans," Smith says, adding that others only operate on people after they graduate.
All 19 accredited optometry schools nationwide teach courses on lasers, according to Smith, also the president of the Association of Schools and Colleges of Optometry, a nonprofit representing the interests of optometric education. However, Smith didn't have precise details about hands-on training. "Every school strives to make sure their graduates are eligible for licensure in every state," he says, meaning they learn skills to match scope of practice and beyond.
However, Briceland says post-optometry school education can amount to weekend courses at the Holiday Inn to learn surgery. "There's no standard of education," he says. While ophthalmologists may also learn new laser techniques at short seminars, Briceland says ophthalmologists already have a broad base of experience. For example, they perform many different surgeries, from Lasik to cataract surgery, on human patients during medical school, internships, residencies and up to two years of optional fellowship training. "How can you claim four years of post-college education is the same as 8 to 10?" Briceland asks. "You can't."
Educational differences didn't stop Kentucky optometrists, who successfully pushed to become the second state nationwide to allow them to perform some laser surgeries. A strong bipartisan majority passed the bill in February and Gov. Steve Beshear signed it into law the same month. "This new law will mean more Kentuckians can get the eye care they need," Beshear said, pledging that optometrists who expand scope of practice will undergo extensive training. In addition to surgery, the Kentucky law gives optometrists the ability to administer injections like local anesthesia, prescribe more drugs and grants the state optometry board broad authority to further expand scope of practice, save for prohibited procedures like PRK and Lasik.
Critics say nearly $400,000 in campaign contributions was responsible for the legislation's swift approval. "The optometrists had an excellent lobby," says state Rep. Susan Westrom, one of only a few legislators who voted against the law. She contends it was rushed through: "I don't think we can trust the outcome because we didn't have all the information."
Though Westrom goes to an optometrist and considers their role integral to eye care, she sees no reason for the broad expansion of practice. Woodford Van Meter, a highly rated ophthalmologist in Lexington, Ky., and president of the Kentucky Academy of Eye Physicians and Surgeons, agrees with her. "There's never been a consumer group, an advocacy group or a patient group that's said this is a good idea," he says.
But Reynolds believes expanded services are a logical step in the evolution of primary eye care. "I think that if consumer groups were properly educated on it, if they could look at the educational background of optometry [and] at the history of safety of optometrists, they would be in favor of these procedures," he says.