If you need laser eye surgery in the state of Kentucky, or a little cosmetic work around the eyelids, it now behooves you to ask your prospective surgeon the following question before signing the operative consent form:
"Say doc, did you go to medical school?"
Kentucky joined the company of Oklahoma last week as the second state to conflate optometrists and ophthalmologists. Only ophthalmologists are the sort of doctors who graduated from medical school, did an internship, completed a three-year residency in eye surgery, possibly a fellowship after that, and have achieved and maintained national board certification through a program of lifelong learning in their specialty.
Optometry schools (four-year programs focused on optics to prescribe glasses and contacts and the diagnosis and management of certain eye-related diseases) have a tough application process too, and many of the same students going into optometry could have chosen medicine. But nobody ever really faces a clear-cut choice of going into optometry or ophthalmology. Even if you do exceedingly well in medical school, you could easily miss out on an ophthalmology residency slot. Ophthalmology is among the most selective specializations in medicine. Yet despite having earned a reputation within medical science as one of its most advanced and storied fields, these days ophthalmology is challenged with its branding, of all things. Perhaps it's the funny spelling?
Nationwide, about 30 percent of consumers don't know the difference between the two types of eye doctors, according to a survey conducted by the National Consumer's League (the NCL designed the study independently, then applied for and received unrestricted funding from the American Academy of Ophthalmology, which did not commission the study). Ninety-five percent of the 600 Americans surveyed wanted an M.D. wielding the scalpel or the laser if they needed eye surgery. Regular everyday people seem to sense that the eyes are part of the body, that serious disease might have something to do with the whole, and that at the very least, you might want a full-service clinician involved if something becomes complicated enough for an invasive procedure.
Proponents of optometry's expansion argued that having optometrists perform in-office laser eye procedures, inject medications into eyes, and cut out "lumps and bumps" around the eyes increases health care access for Kentucky's rural citizens (Kentucky's Medicaid program can spend $150 in transportation credits for a $50 ophthalmology check-up). Optometrists outnumber ophthalmologists by a ration of four to one and can be found in most Kentucky counties.
But while you could easily be forgiven for imagining that Kentucky's leadership must now be hot on the trail of other ways to foster health care accessibility, like chiropractic spine surgery or cosmetic surgery parlors, do not expect the complete democratization of medicine until back adjusters and cosmetologists can pay to play with the same skill as optometrists. Mistaking optometry for ophthalmology was no Mr. Magoo moment.
"If you go back and look at our involvement in politics in terms of contributions, we've always been involved," says Dr. Ian Benjamin Gaddie, president-elect of the Kentucky Optometric Association. "We work hand-in-hand in the community with these people and that makes a huge difference."
Efforts included lobbying state legislators while they were immobilized in the optometric examining chair, reports indicate.
"In many states it's just how the stars line up, and how your luck goes as you run the gamut through the political process," Dr. Gaddie told me.
The Louisville Courier-Journal's Frankfort bureau chief Tom Loftus followed the blue grass stardust:
"Kentucky optometrists and their political action committee have given campaign money to 137 of the 138 members of the state legislature and Gov. Steve Beshear, contributing more than $400,000 as they push for a bill to expand their practices.
Members of the Kentucky Optometric Association and its PAC have given at least $327,650 to legislative candidates in the last two years alone and have hired 18 lobbyists to help them make their case.
They also gave a total of at least $74,000 more to Beshear's re-election campaign, the Republican gubernatorial campaign of Senate President David Williams and the House and Senate political caucuses."
Optometry waged state-by-state expansion of practice battles for four decades on its way to where the profession stands now, which is increasingly nebulous. The American Academy of Ophthalmology and the American Medical Association have challenged optometry every step as optometry blurs its boundaries with medicine. A patchwork quilt of legislation around the country variably delineates optometric practice. Now two patches have little pockets for scalpels and lasers.
For optometrists, serving us as the "primary health care professional for the eye" means what the state says it does, and that can vary widely, creating confusion among patients and the rest of the medical world. Citing how in some states optometrists must obtain certifications for medications they have no intention of ever using, the American Society of Health-System Pharmacists pointed to optometrist licensure as an example to avoid.
Optometrists have been dilating eyes since the 1970s to better diagnose eye diseases, and have been using local medications in most states since the 1980s. They no longer face opposition from ophthalmology on these fronts. "We draw the philosophical line in the sand with surgery," says Dr. David Parke, chief executive officer of the American Academy of Ophthalmology.
Ophthalmologists have successfully fought back in 25 other state battles where optometrists asked legislatures to let them perform surgery, he says, by pointing out the difference in quality of training and management of adverse events.
While chair of the University of Oklahoma's Department of Ophthalmology for 17 years, Dr. Parke dealt with the aftermath of upgraded optometric licensure in that state. He says the problems he saw were the result of "not knowing what you don't know."
Dr. Parke's experience included treating a man whose "skin tag" was excised by an optometrist. Nine months later the patient came to the university medical center with an invasive, substantive squamous cell carcinoma that required a massive reconstructive surgery. "We asked the patient, 'Why'd you let him do that?' He replied, 'Well he's a doctor, he had on a white coat and he said he could.'"
In another case, an elderly patient with severe end-stage glaucoma could only be controlled surgically through a technique called filtering blebs. "She went to an optometrist who said to the patient, 'Mrs. Jones, you have cysts on your eyes, I should take care of those now,' and he proceeded to excise them, completely undoing the surgery."
"In the end it scares me, quite frankly," says Dr. Parke.
The most common laser procedure Kentucky optometrists will perform involves using a YAG laser to clear a membrane that becomes cloudy in some patients after lens replacement surgery (it's something ophthalmologists do as needed on post-cataract surgery follow-up appointments). The procedure may take only 20 minutes to learn and looks as simple as a video game. But complications can occur.
"You can be a pilot, and say, 'I'm just going to fly in good weather' -- but you never know when it's gonna get dark, or when the storm's gonna come up," says Dr. Woodford Van Meter, president of the Kentucky Academy of Eye Physicians and Surgeons. "You can go get an amateur pilot's license, but that doesn't mean you should fly a jetliner full of passengers down to Florida."
But ophthalmologists can only convey their concerns when they're given enough time. By the immaculate design of 18 lobbyists, the ophthalmologists knew about the Kentucky bill just 12 hours before it entered a Senate committee (bypassing a customary 72-hour holding period), and sailed through that committee to the Senate floor the next day. The whole process, from the bill's first public posting to the Governor signing it into law, took 17 days, bypassing hundreds of other bills filed well before it. "It was a juggernaut. It was an advancing force that seemed to crush everything under its path," Tom Loftus said on the KET program Comment on Kentucky.
Dr. Van Meter says he and his colleagues got 10 minutes total to make their case at an informational hearing put together at the last minute in the Kentucky Senate.
"The people pushing the bill to me looked like your dog when you come into the kitchen and he's taken a piece of meat of your plate," Dr. Van Meter told me. "He just looks guilty as sin, but he's sitting there smiling with big eyes like nothing in the world ever happened."
The bill itself looks like a rush job. It even includes an anatomical error. It prohibits optometrists from injecting into the posterior chamber of the eye (nobody can, it's too small a space). Presumably that line meant to state that optometrists cannot inject into the posterior segment of the eye, which includes the vitreous. Because of the sloppy writing, now optometrists can inject into the posterior segment, using drugs like Lucentis to treat macular degeneration. The bill also excludes optometrists from performing two common excimer laser corrective vision procedures, LASIK and PRK, but leaves out another common procedure, LASEK.
Dr. Ben Gaddie admits the LASEK loophole exists, but he expects the optometry board won't allow excimer laser procedures at all, following the spirit of the legislation if not its wording. However, he's not on the optometry board.
Dr. Van Meter and other state ophthalmology leaders sat down with Kentucky's governor to make their case as he weighed whether to sign the bill that had arrived on his desk with such urgency. They were a little flummoxed when it became apparent the governor had little issue with the idea that providers who didn't go to medical school would be doing surgery. "He seemed to think that was okay," Dr. Van Meter observes.
I asked the governor, who was on the road attending the National Governor's Association Winter Meeting in D.C. this weekend, whether he was now pioneering the way for other states in redefining optometry. He's making no such stand. Beshear based his decision "solely on what is best for the people of Kentucky. Under that framework, improving access to health care of all kinds is a priority for Kentuckians. Other states must make their own determinations for what is best for their citizens," he wrote in an email.
Elaborating on the access issue, Beshear wrote, "there are fewer ophthamologists in Kentucky than optometrists, and at times, it may be easier for residents (especially in rural areas) to get access to an optometrist for needed eye care. There will be times when citizens will require the services of an ophthalmologist; however, this legislation will allow Kentuckians to have more options in accessing proper eye care."
Naturally I wanted to know whether the governor would choose the care of an ophthalmologist or an optometrist should he need an eye surgery now in the optometry's purview. Maybe he'll simply pick the geographically closest provider, like he expects the disadvantaged Appalachian citizens of his state will do? He didn't answer that one.
What's optometry's end game, if the field sees itself as the primary care providers for the eye? "It's hard for me to fathom that the end goal of the organized profession of optometry is to go in and do routine intraocular surgery like retinal disease or cataract surgery or incisional glaucoma surgery," says Dr. Ben Gaddie. He believes that the minor surgical procedures with scalpels and lasers Kentucky now allows fit into the "primary care" mold.
It sure sounds specialized to me. The eye is part of the central nervous system. I don't know too many primary care docs who do a little bit of neurosurgery or plastic surgery on the side. There's a reason the rest of medicine organizes itself into cardiologists and cardiovascular surgeons, neurologists and neurosurgeons, and so on. There's a reason you want a surgeon to do surgery. They do a lot, and they do it well. It's worth a little drive.
"I give the optometrists an A+ in politics," says Dr. Parke of the ophthalmology association. "I may give them an F in being an effective advocate for patient safety and quality of care."
A new anatomical understanding of how movement controls the body’s stress response system
Elite tennis players have an uncanny ability to clear their heads after making errors. They constantly move on and start fresh for the next point. They can’t afford to dwell on mistakes.
Peter Strick is not a professional tennis player. He’s a distinguished professor and chair of the department of neurobiology at the University of Pittsburgh Brain Institute. He’s the sort of person to dwell on mistakes, however small.
“My kids would tell me, dad, you ought to take up pilates. Do some yoga,” he said. “But I’d say, as far as I’m concerned, there's no scientific evidence that this is going to help me.”
Still, the meticulous skeptic espoused more of a tennis approach to dealing with stressful situations: Just teach yourself to move on. Of course there is evidence that ties practicing yoga to good health, but not the sort that convinced Strick. Studies show correlations between the two, but he needed a physiological mechanism to explain the relationship. Vague conjecture that yoga “decreases stress” wasn’t sufficient. How? Simply by distracting the mind?
The inequality at the heart of America’s education system
HARTFORD, Conn.—This is one of the wealthiest states in the union. But thousands of children here attend schools that are among the worst in the country. While students in higher-income towns such as Greenwich and Darien have easy access to guidance counselors, school psychologists, personal laptops, and up-to-date textbooks, those in high-poverty areas like Bridgeport and New Britain don’t. Such districts tend to have more students in need of extra help, and yet they have fewer guidance counselors, tutors, and psychologists, lower-paid teachers, more dilapidated facilities and bigger class sizes than wealthier districts, according to an ongoing lawsuit. Greenwich spends $6,000 more per pupil per year than Bridgeport does, according to the State Department of Education.
If Hillary Clinton beats Donald Trump, her party will have set a record in American politics.
If Donald Trump can’t erase Hillary Clinton’s lead in the presidential race, the Republican Party will cross an ominous milestone—and confront some agonizing choices. Democrats have won the popular vote in five of the six presidential elections since 1992. (In 2000, Al Gore won the popular vote but lost the Electoral College and the White House to George W. Bush.) If Clinton maintains her consistent advantage in national and swing-state polls through Election Day, that means Democrats will have won the popular vote in six of the past seven presidential campaigns.
Since the 1828 election of Andrew Jackson that historians consider the birth of the modern two-party system, no party has ever won the presidential popular vote six times over seven elections. Even the nation’s most successful political figures have fallen short of that standard.
City dwellers spend nearly every moment of every day awash in Wi-Fi signals. Homes, streets, businesses, and office buildings are constantly blasting wireless signals every which way for the benefit of nearby phones, tablets, laptops, wearables, and other connected paraphernalia.
When those devices connect to a router, they send requests for information—a weather forecast, the latest sports scores, a news article—and, in turn, receive that data, all over the air. As it communicates with the devices, the router is also gathering information about how its signals are traveling through the air, and whether they’re being disrupted by obstacles or interference. With that data, the router can make small adjustments to communicate more reliably with the devices it’s connected to.
Do mission-driven organizations with tight budgets have any choice but to demand long, unpaid hours of their staffs?
Earlier this year, at the encouragement of President Obama, the Department of Labor finalized the most significant update to the federal rules on overtime in decades. The new rules will more than double the salary threshold for guaranteed overtime pay, from about $23,000 to $47,476. Once the rules go into effect this December, millions of employees who make less than that will be guaranteed overtime pay under the law when they work more than 40 hours a week.
Unsurprisingly, some business lobbies and conservatives disparaged the rule as unduly burdensome. But pushback also came from what might have been an unexpected source: a progressive nonprofit called the U.S. Public Interest Research Group (PIRG). “Doubling the minimum salary to $47,476 is especially unrealistic for non-profit, cause-oriented organizations,” U.S. PIRG said in a statement. “[T]o cover higher staffing costs forced upon us under the rule, we will be forced to hire fewer staff and limit the hours those staff can work—all while the well-funded special interests that we're up against will simply spend more.”
In the name of emotional well-being, college students are increasingly demanding protection from words and ideas they don’t like. Here’s why that’s disastrous for education—and mental health.
Something strange is happening at America’s colleges and universities. A movement is arising, undirected and driven largely by students, to scrub campuses clean of words, ideas, and subjects that might cause discomfort or give offense. Last December, Jeannie Suk wrote in an online article for The New Yorker about law students asking her fellow professors at Harvard not to teach rape law—or, in one case, even use the word violate (as in “that violates the law”) lest it cause students distress. In February, Laura Kipnis, a professor at Northwestern University, wrote an essay in The Chronicle of Higher Education describing a new campus politics of sexual paranoia—and was then subjected to a long investigation after students who were offended by the article and by a tweet she’d sent filed Title IX complaints against her. In June, a professor protecting himself with a pseudonym wrote an essay for Vox describing how gingerly he now has to teach. “I’m a Liberal Professor, and My Liberal Students Terrify Me,” the headline said. A number of popular comedians, including Chris Rock, have stopped performing on college campuses (see Caitlin Flanagan’s article in this month’s issue). Jerry Seinfeld and Bill Maher have publicly condemned the oversensitivity of college students, saying too many of them can’t take a joke.
The global education pioneer eases students into the classroom.
Heading into my first year of teaching in Helsinki I felt pretty nervous. One of my graduate-school professors—a former Massachusetts Teacher of the Year—had warned me that Finnish students were academically advanced, especially in math. Indeed, Finland’s students had excelled on international standardized tests like the PISA for more than a decade. But it wasn’t just those high-performing Finnish students that intimidated me. Their teachers did, too.
If I had chosen to pursue master’s-level training as an elementary-school teacher in Finland (instead of the United States), I would have applied to the small handful of teacher-training universities, where annual acceptance rates hover around 10 percent. These programs are so selective, claimed The Atlantic journalist Amanda Ripley in her book, The Smartest Kids in the World, they’re “on the order of MIT.” Furthermore, Finland’s classroom teacher-training programs require five years of coursework, practicum, and thesis writing. The Finnish version made my two-year master’s degree in elementary education, through a non-selective college in the Boston area, look quite humble.
A study in mice looks at the risks of vaginal infection.
It was just last month that the first case of a woman spreading Zika sexually to her male partner was documented, and around the same time that a study found the virus in a woman’s cervical mucus 11 days after infection. Before that, most of the talk about sexual transmission of the normally mosquito-borne virus focused on semen, where Zika can survive for a long time. (A recent report puts it at up to six months.)
But it’s starting to look like the vagina is very hospitable to Zika as well. Which is alarming, given the severity of the birth defects Zika can cause. So far there are only case studies in humans, but a new study in mice found that the female reproductive tract is “a highly susceptible site of ZIKV replication.”
No one will ever find a closer exoplanet—now the race is on to see if there is life on its surface.
One hundred and one years ago this October, a Scottish astronomer named Robert Innes pointed a camera at a grouping of stars near the Southern Cross, the defining feature of the night skies above his adopted Johannesburg. He was looking for a small companion to Alpha Centauri, our closest neighboring star system.
Hunched over glass photographic plates, Innes teased out a signal. Across five years of images, a small, faint star moved, wiggling on the sky. It shifted just as much as Alpha Centauri, suggesting its fate was intertwined with that binary system. But this small star was closer to the sun than Alpha. Innes suggested calling it Proxima Centauri, using the Latin word for “nearest.”
The dim red star soon entered the collective imagination, inspiring dreams of interstellar travel. Gravity has linked the star to the Alpha Centauri system, but our culture of science and storytelling has linked it to the solar system. Today, that link will grow stronger, when an international team of astronomers announces that this nearest of stars also hosts the closest exoplanet, one that might look a whole lot like Earth.
A recent scholarly paper on “microaggressions” uses them to chart the ascendance of a new moral code in American life.
Last fall at Oberlin College, a talk held as part of Latino Heritage Month was scheduled on the same evening that intramural soccer games were held. As a result, soccer players communicated by email about their respective plans. “Hey, that talk looks pretty great,” a white student wrote to a Hispanic student, “but on the off chance you aren’t going or would rather play futbol instead the club team wants to go!!”
Unbeknownst to the white student, the Hispanic student was offended by the email. And her response signals the rise of a new moral culture America.
When conflicts occur, sociologists Bradley Campbell and Jason Manning observe in an insightful new scholarly paper, aggrieved parties can respond in any number of ways. In honor cultures like the Old West or the street gangs of West Side Story, they might engage in a duel or physical fight. In dignity cultures, like the ones that prevailed in Western countries during the 19th and 20th Centuries, “insults might provoke offense, but they no longer have the same importance as a way of establishing or destroying a reputation for bravery,” they write. “When intolerable conflicts do arise, dignity cultures prescribe direct but non-violent actions.”