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."
For centuries, philosophers and theologians have almost unanimously held that civilization as we know it depends on a widespread belief in free will—and that losing this belief could be calamitous. Our codes of ethics, for example, assume that we can freely choose between right and wrong. In the Christian tradition, this is known as “moral liberty”—the capacity to discern and pursue the good, instead of merely being compelled by appetites and desires. The great Enlightenment philosopher Immanuel Kant reaffirmed this link between freedom and goodness. If we are not free to choose, he argued, then it would make no sense to say we ought to choose the path of righteousness.
Today, the assumption of free will runs through every aspect of American politics, from welfare provision to criminal law. It permeates the popular culture and underpins the American dream—the belief that anyone can make something of themselves no matter what their start in life. As Barack Obama wrote in The Audacity of Hope, American “values are rooted in a basic optimism about life and a faith in free will.”
George Will is denouncing a GOP that has been ailing for years, but quitting won’t help—an American political party can only be reformed from within.
This past weekend, George Will revealed that he had formally disaffiliated himself from the Republican Party, switching his Maryland voter registration to independent. On Fox News Sunday, the conservative pundit explained his decision: "After Trump went after the 'Mexican' judge from northern Indiana then [House Speaker] Paul Ryan endorsed him, I decided that in fact this was not my party anymore.” For 40 years, George Will defined and personified what it meant to be a thoughtful conservative. His intellect and authority inspired a generation of readers and viewers, myself very much among them.
His departure represents a powerful image of divorce between intellectual conservatism and the new Trump-led GOP. Above all, it raises a haunting question for the many other Republicans and conservatives repelled by the looming nomination of Donald Trump as the Republican candidate for president of the United States: What will you do?
Hillary Clinton wrote something for The Toast today. Are you sobbing yet?
Either you’ll immediately get why this is crazy, or you won’t: Hillary Clinton wrote a thing for The Toast today.
Are you weeping? Did your heart skip a beat? Maybe your reaction was, “What. Whaaaat. WHAT,” or “Aaaaaaahhhhhhh!!!” or “OH MY GOD,” or simply “this is too much goodbye I'm dead now.”
Perhaps your feelings can only be captured in GIF form, as was the case for someone commenting on Clinton’s post under the name Old_Girl:
Reader comments like the ones above are arguably the best part of Clinton’s post, because they highlight just how meaningful hearing directly from Clinton is to The Toast’s community of readers. The Toast is a small but beloved feminist website known for its quirky literary humor. It announced last month it couldn’t afford to continue operating. Friday is its last day of publication.
“This western-front business couldn’t be done again.”
On this first day of July, exactly 100 years ago, the peoples of the British Empire suffered the greatest military disaster in their history. A century later, “the Somme” remains the most harrowing place-name in the annals not only of Great Britain, but of the many former dependencies that shed their blood on that scenic river. The single regiment contributed to the First World War by the island of Newfoundland, not yet joined to Canada, suffered nearly 100 percent casualties that day: Of 801 engaged, only 68 came out alive and unwounded. Altogether, the British forces suffered more than 19,000 killed and more than 38,000 wounded: almost as many casualties in one day as Britain suffered in the entire disastrous battle for France in May and June 1940, including prisoners. The French army on the British right flank absorbed some 1,600 casualties more.
It happened gradually—and until the U.S. figures out how to treat the problem, it will only get worse.
It’s 2020, four years from now. The campaign is under way to succeed the president, who is retiring after a single wretched term. Voters are angrier than ever—at politicians, at compromisers, at the establishment. Congress and the White House seem incapable of working together on anything, even when their interests align. With lawmaking at a standstill, the president’s use of executive orders and regulatory discretion has reached a level that Congress views as dictatorial—not that Congress can do anything about it, except file lawsuits that the divided Supreme Court, its three vacancies unfilled, has been unable to resolve.
On Capitol Hill, Speaker Paul Ryan resigned after proving unable to pass a budget, or much else. The House burned through two more speakers and one “acting” speaker, a job invented following four speakerless months. The Senate, meanwhile, is tied in knots by wannabe presidents and aspiring talk-show hosts, who use the chamber as a social-media platform to build their brands by obstructing—well, everything. The Defense Department is among hundreds of agencies that have not been reauthorized, the government has shut down three times, and, yes, it finally happened: The United States briefly defaulted on the national debt, precipitating a market collapse and an economic downturn. No one wanted that outcome, but no one was able to prevent it.
What percentage graduated from high school and enrolled within a year at a four year institution where they live on campus?
Who are today’s college students?
The answer surprises most people who attended four year universities, according to Jamie Merisotis, President and CEO of Lumina Foundation. Addressing audiences, like the one he spoke to Friday at The Aspen Ideas Festival, co-hosted by the Aspen Institute and The Atlantic, he frequently poses this question: “What percentage of students in American higher education today graduated from high school and enrolled in college within a year to attend a four year institution and live on campus?”
Most people guess “between forty and sixty percent,” he said, whereas “the correct answer is five percent.” There is, he argued, “a real disconnect in our understanding of who today’s students are. The influencers––the policy makers, the business leaders, the media––have a very skewed view of who today’s students are.”
The trend helps explain Trump and Brexit. What’s next?
On Wednesday, Facebook made an announcement that you’d think would only matter to Facebook users and publishers: It will modify its News Feed algorithm to favor content posted by a user’s friends and family over content posted by media outlets. The company said the move was not about privileging certain sources over others, but about better “connecting people and ideas.”
But Richard Edelman, the head of the communications marketing firm Edelman, sees something more significant in the change: proof of a new “world of self-reference” that, once you notice it, helps explain everything from Donald Trump’s appeal to Britain’s vote to exit the European Union. Elites used to possess outsized influence and authority, Edelman notes, but now they only have a monopoly on authority. Influence largely rests with the broader population. People trust their peers much more than they trust their political leaders or news organizations.
There needs to be more nuanced language to describe the expanding demographic of unmarried Americans.
In 1957, a team of psychology professors at the University of Michigan released the results of a survey they had conducted—an attempt to reflect Americans’ attitudes about unmarried people. When it came to the group of adults who remained single by choice, 80 percent of the survey’s respondents—reflecting the language used by the survey’s authors—said they believed that the singletons remained so because they must be “immoral,” “sick,” or “neurotic.”
It’s amazing, and reassuring, how much has changed in such a relatively narrow slice of time. Today, certainly, marriage remains a default economic and social arrangement, particularly after having been won as a right for same-sex couples; today, certainly, those who do not marry still face some latent social stigmas (or, at the very least, requests to explain themselves). But the regressive language of failed morality and psychological pathology when it comes to singledom? That has, fortunately, been replaced by more permissive attitudes.
The relationship therapist Esther Perel thinks so—and argues that it’s time to rethink matrimony and, with it, infidelity.
Think of the last wedding you attended. Did the couple’s vows to each other involve promises to be, for the rest of their lives, friends and family and companions and lovers and allies? Did the two people vow to keep exciting each other and soothing each other and listening to each other and challenging each other, to be co-adventurers and co-Netflixers and co-owners of things and possibly co-parents of things and, all in all, pretty much all things to each other?
If so, the couple is very modern. Marriage has spent most of its existence, in the West and elsewhere, as primarily an economic arrangement; as a result, it has also spent most of its existence much less laden with the emotional expectation that we tend to heap upon it today. The current romantic conception of marriage—evident in the culture not just in the guise of hopeful wedding vows, but also in the wedding industrial complex and in pretty much every Hollywood rom-com that defines its “happy ending” according to the satisfactions of long-term commitment—is the result of historical coincidence. It arose, the Belgian relationship therapist Esther Perel argues, from a collision of several forces that collided in the 19th and 20thcenturies: among them capitalism, latent Romanticism, and the political and cultural notion of the primacy of the individual.
How much do you really need to say to put a sentence together?
Just as fish presumably don’t know they’re wet, many English speakers don’t know that the way their language works is just one of endless ways it could have come out. It’s easy to think that what one’s native language puts words to, and how, reflects the fundamentals of reality.
But languages are strikingly different in the level of detail they require a speaker to provide in order to put a sentence together. In English, for example, here’s a simple sentence that comes to my mind for rather specific reasons related to having small children: “The father said ‘Come here!’” This statement specifies that there is a father, that he conducted the action of speaking in the past, and that he indicated the child should approach him at the location “here.” What else would a language need to do?