Devil's advocate: OD-performed surgery dangerous, but could 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.

On April 19, I received an e-mail from the American Academy of Ophthalmology. It expressed concern with a recent proposed change to the policy of the California Professions and Economic Development Committee regarding scope of practice for-among other professionals-optometrists.

In the e-mail I read that “state Sen. Ed Hernandez (D-West Covina), a practicing optometrist” has sponsored SB 622 that would allow optometrists to perform eyelid procedures, glaucoma laser surgery, inject medicines (including intravitreal), give vaccines, and use antimetabolites. I am also informed that the above would require “minimal education and training” and that I ought to “send an urgent message to [my] state senator, committee member, and staff” because “patient safety is at risk.”

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I have read SB 622, and I’ve found that the details are more revealing than the headlines. Much of what I’ve heard from my colleagues surrounding this new law seems to relay the latter. For a full reading, see the link provided below.¹

Here are a couple pertinent portions: 

For eyelid procedures, optometrists will be allowed to perform "removal, destruction, or drainage of lesions of the eyelid and adnexa clinically evaluated by the optometrist to be noncancerous, not involving the eyelid margin, lacrimal supply or drainage systems, no deeper than the orbicularis muscle, and smaller than five millimeters in diameter . . . local anesthesia techniques and complications . . . treatment of anaphylaxis . . . radiofrequency surgery . . . [and] postoperative wound care.”

Next: What is SB 622 really getting at?

Training involved will be coincident to training for glaucoma-related and other laser procedures.

In other words, if optometry students are learning lid procedures, they will also receive glaucoma laser training. Students will undergo a course “32 hours in length and include a test for competency . . . the school of optometry shall require each applicant . . . to perform a sufficient number of minor procedures to verify that the applicant has demonstrated competency to practice independently. At a minimum, each applicant shall complete five minor procedures on live humans.”

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For laser procedures, optometrists will perform “at a minimum . . . 14 anterior segment laser procedures on live humans” prior to certification. For this and the above, a pilot program will be initiated to evaluate “expanded roles” not simply for the management of eye conditions, but for “the performance of management and treatment of diabetes mellitus, hypertension, and hypercholesterolemia” (see section 12). 

In ophthalmology training, the Accreditation Council for Graduate Medical Education (ACGME) requires residents to perform 86 cataract surgeries, 5 YAGs, 5 trabeculoplasties, 4 laser iridotomies, 10 panretinal photocoagulation procedures, 3 pterygium removals, 10 strabismus procedures, 5 glaucoma filtering procedures, 10 intravitreal injections, 28 oculoplastics (mixed), and 4 globe trauma repairs.

I remember when I was in internship, and my internal medicine attending asked me to define Type 2 Diabetes Mellitus. Like any good medical student (my level of understanding at that point), I recited the diagnostic criteria: fasting blood glucose above 126 mg/dL, random blood glucose of above 200 mg/dL with symptoms, and so on.

His response is one of those things you can’t forget, no matter how early in the morning. He knew I intended to be an ophthalmologist.

He asked something like: “When a thin patient enters your clinic with diabetic retinopathy and tells you that he is ‘borderline,’ what are you going to tell him about the diagnostic criteria?” 

That is when, for the first time, I took a clear view into the complex valley that is Type 2 Diabetes. I saw that the ideas surrounding the organization of the diagnostic criteria are probably more important than the numbers of the rubric itself.

I realized that my attending was attempting to shed my ignorant understanding of the disease, despite my passion to get a good review. I found out that this seemingly routine concern is actually rather complex, and that a sophisticated understanding of its underlying assumptions is necessary in explaining the concern to patients and for organizing follow-up. I also discovered, rather convincingly, that I didn’t want to pursue internal medicine.

Next: You're making a political institution the sole proprietor

My approach with the diabetic patient has never been the same. I’m not an endocrinologist, but I can speak with some sophistication about the life of a diabetic and tailor a discussion about its connection with the eye. But that’s probably not the most important part.

I can see now how the above education allows me to set the tone and give patients the correct expectations about their disease. I truly wonder how much of that can occur without an enriched exposure to the medical wards or hospital training as would be the case when an optometrist is tasked with the “management and treatment of diabetes mellitus, hypertension, and hypercholesterolemia.”

When people like John Rosten, immediate past-president of the California Optometric Association, write that “Californians already lack access to basic medical care,” you can probably see what kind of argument he is attempting to construct, that he may be attempting to bypass the above refinements obtained during medical school and residency.²

His reasoning probably follows the idea that there is an increasing need for primary care, and that there are only so many medical school graduates to meet supply, therefore we ought to look to others to meet demand. Add a salty discussion on the recent “measles and whooping cough outbreaks in California,” and the syllogism is completed on a foundation with advocacy surrounding something as harmless as vaccination.

Admit it, you don't know everything

Notice several things. You, the reader, are probably concerned about the above, but do you know why you are concerned? You’re probably thinking that anyone without a medical degree should basically prescribe glasses. But realize that what you are doing is asking a political institution to, by force, make you the sole proprietor of a certain list of procedures and diseases. That approach may also produce a more ruinous situation.

When you purchase the services of an Internet service provider (ISP), how do you feel when you hear Comcast claim that their product is excellent and that only they will be your sole provisioner? Would you sacrifice their e-mail services (if you’re under 40, you probably don’t know that you’re purchasing an e-mail account) for a cheaper product? Would you agree to work with another company, get faster and more reliable connection, but receive less human-interaction over the telephone for tech support?

This is essentially the Google Fiber versus the Verizon-Comcast-Cox Polycephaly of all evilness situations. If this is the first time you’re hearing of Google’s competing ISP, you ought to do yourself a favor and spend 5 minutes online to see what glee is aroused by the simple idea that the Internet in the country of its founding should meet quality measures typical of an Estonian village.

Monopoly, on the whole, is a bad thing, even in medicine. Decreased variety within any market leads to poor quality and decreased creativity and ingenuity. We all, even we ophthalmologists, recognize this naturally occurring phenomenon in all other human interactions.

I can’t see any specific reason why it shouldn’t apply to our profession. 

Next: 'I don't think that eyes or bodies are the same as your Netflix subscription'

No, I don’t think that eyes or bodies are the same as your Netflix subscription. The principles that predict the undesired results of monopoly are, however, as predictable as gravity-both are spontaneous. You have to face the idea that you are promoting monopoly when you risk the proposition that there ought to be a protected list of procedures or ideas that other professionals may not entertain.

The deleterious results of monopoly ought not to be listed here, as I’m sure you’ve grown emotionally attached to them in your struggles to download iTunes files at 8 p.m. on a Sunday evening. 

Prices are too high for our patients, and it turns out that they have to pay for our work. Those for whom we claim to care about are paying prices that are too high, the consequences of which could lead to an all-or-none situation if they have nowhere else to go.

I cannot fully enter into a discussion about what reasons those prices may be elevated (a subject perhaps for a later post). However, the idea that only a limited clergy can perform procedures means limited supply in the setting of increasing demand.

In other words, a desire to retain monopoly is a desire for decreased access or decreased longevity of our medical system or decreased health of our patients. To quote the Academy, “patient safety is at risk.”

There may be a greater principle here, one that we spend considerable time and energy respecting and discussing in medical school. This is the idea that the ultimate arbiter of the patient’s body is the patient, and that the locus of discretion ought to rest with her.

Any effort to thwart patients’ options-in my view-is one that cannot, by definition, guarantee favorable outcomes morally or meet our daily ritual of ensuring autonomy. If a patient would like to undergo a lid procedure or YAG capsulotomy with an unlicensed or under-qualified practitioner, that is his or her decision because he or she lives with the consequences. If we write into law the practice of placing a police officer (don’t kid yourself, that is what you’re asking for) between the patient and the practitioner, then we have committed a moral crime in violation of greater, more basic liberties. 

Next: 'Perhaps we ought to be humble'

Perhaps we ought to be humble and recognize that something is better than nothing. Maybe an optometrist cannot fully inform their patients about the intimate details and pathophysiology of diabetic retinopathy, but at least they can see the patient and provide some form of a therapy even if it may be limited. 

Ophthalmology education is valuable-I’m not saying it’s not. In training, the ACGME requires residents to perform 86 cataract surgeries, 5 YAGs, 5 trabeculoplasties, 4 laser iridotomies, 10 panretinal photocoagulation procedures, 3 pterygium removals, 10 strabismus procedures, 5 glaucoma filtering procedures, 10 intravitreal injections, 28 oculoplastics (mixed), and 4 globe trauma repairs. I’m PGY2 and I’ve already completed half of the above within my first 8 months.

Undoubtedly, those who can go to the MD will receive superior quality if the market for eye or other care is opened.

The idea of certification is still intact, and frankly I foresee a more informed patient population under these proposed circumstances, which may lead to an increase in patient demand for MD-based care.

Am I the only person who has to inform my patients that I am an eye surgeon, not someone whose primary responsibility is to provide spectacles? 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 once we prove that our results are better.

If this is really about patient safety, we will see the fruits of our education when we test our ideology. Maybe (gasp) we’re wrong about some portions of medical education or the value of our medical degree.

What parts are important and, more importantly what parts are not useful to patients, will be less easily reviewed unless results are met with real-world challenges. Perhaps opening the market for optometrists will lead to more innovations that will produce a wider scope of practice for MDs who undergo more training.

Were it not for practices of this sort, we might still be using a Carterfone³ or shopping at Safeway. I’d rather have my iPhone.

References

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

[2] http://www.sacbee.com/opinion/op-ed/soapbox/article17746358.html

[3] http://bpastudio.csudh.edu/fac/lpress/471/hout/telecomHistory/