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."
Biology textbooks tell us that lichens are alliances between two organisms—a fungus and an alga. They are wrong.
In 1995, if you had told Toby Spribille that he’d eventually overthrow a scientific idea that’s been the stuff of textbooks for 150 years, he would have laughed at you. Back then, his life seemed constrained to a very different path. He was raised in a Montana trailer park, and home-schooled by what he now describes as a “fundamentalist cult.” At a young age, he fell in love with science, but had no way of feeding that love. He longed to break away from his roots and get a proper education.
At 19, he got a job at a local forestry service. Within a few years, he had earned enough to leave home. His meager savings and non-existent grades meant that no American university would take him, so Spribille looked to Europe.
Taking over Stephen Colbert’s Late Show to blast Fox News, the former ‘Daily Show’ host was unapologetically partisan while also seeking to build bridges.
There are so many things that make this election season one without precedent. Why, then, has a faction of late-night punditworld responded with a reversion? Earlier this week, Stephen Colbert resurrected his satirical “Stephen Colbert” character, and then, last night, he invited the retired Jon Stewart to take over his Late Night desk for a classic 10-minute Daily Show rant. The biggest shock: The routines have felt vital and fresh, not mere nostalgia bait or retreads.
The reason for the throwback to golden-years Comedy Central fake news probably lies in politics itself. Stewart’s and Colbert’s original heydays were during the George W. Bush era; their entire personas are based not on indiscriminately satirizing the entire world’s absurdities but rather the particular absurdities of America’s right wing. Under Obama, that meant a certain amount of punching down. Donald Trump’s Republican National Convention, though, offered an even more unvarnished display of popular conservative thinking, attitudes, opinions, and bluster to hold America’s attention than, well, the last RNC. Colbert’s retitled program this week conveyed his glee at the prospect: “The 2016 Trumpublican Donational Conventrump Starring Donald Trump as the Republican Party* *May Contain Traces of Republican.” (His comparatively deflated DNC title: “The 2016 Democratic National Convincing, A Technically Historic Event: Death. Taxes. Hillary.”)
It’s known as a modern-day hub of progressivism, but its past is one of exclusion.
PORTLAND, Ore.— Victor Pierce has worked on the assembly line of a Daimler Trucks North America plant here since 1994. But he says that in recent years he’s experienced things that seem straight out of another time. White co-workers have challenged him to fights, mounted “hangman’s nooses” around the factory, referred to him as “boy” on a daily basis, sabotaged his work station by hiding his tools, carved swastikas in the bathroom, and written the word “nigger” on walls in the factory, according to allegations filed in a complaint to the Multnomah County Circuit Court in February of 2015.
Pierce is one of six African Americans working in the Portland plant whom the lawyer Mark Morrell is representing in a series of lawsuits against Daimler Trucks North America. The cases have been combined and a trial is scheduled for January of 2017.
One day in February 2009, a 13-year-old boy named Sasha Egger started thinking that people were coming to hurt his family. His mother, Helen, watched with mounting panic that evening as her previously healthy son forgot the rules to Uno, his favorite card game, while playing it. She began making frantic phone calls the next morning. By then, Sasha was shuffling aimlessly around the yard, shredding paper and stuffing it in his pockets. “He looked like an old person with dementia,” Helen later told me.
That afternoon, Sasha was admitted to the hospital, where he saw a series of specialists. One thought Sasha might have bipolar disorder and put him on antipsychotics, but the drugs didn’t help. Helen, a child psychiatrist at Duke University, knew that psychiatric conditions develop gradually. Sasha’s symptoms had appeared almost overnight, and some of them—including dilated pupils and slurred speech—suggested not mental illness but neurological dysfunction. When she and her husband, Daniel, raised these issues, though, one doctor seemed to think they were in denial.
Narcissism, disagreeableness, grandiosity—a psychologist investigates how Trump’s extraordinary personality might shape his possible presidency.
In 2006, Donald Trump made plans to purchase the Menie Estate, near Aberdeen, Scotland, aiming to convert the dunes and grassland into a luxury golf resort. He and the estate’s owner, Tom Griffin, sat down to discuss the transaction at the Cock & Bull restaurant. Griffin recalls that Trump was a hard-nosed negotiator, reluctant to give in on even the tiniest details. But, as Michael D’Antonio writes in his recent biography of Trump, Never Enough, Griffin’s most vivid recollection of the evening pertains to the theatrics. It was as if the golden-haired guest sitting across the table were an actor playing a part on the London stage.
“It was Donald Trump playing Donald Trump,” Griffin observed. There was something unreal about it.
Fulfilling what might be the Russian autocrat’s dearest wish, Trump has openly questioned whether the U.S. should keep its commitments to NATO.
The Republican nominee for president, Donald J. Trump, has chosen this week to unmask himself as a de facto agent of Russian President Vladimir Putin, a KGB-trained dictator who seeks to rebuild the Soviet empire by undermining the free nations of Europe, marginalizing NATO, and ending America’s reign as the world’s sole superpower.
I am not suggesting that Donald Trump is employed by Putin—though his campaign manager, Paul Manafort, was for many years on the payroll of the Putin-backed former president of Ukraine, Viktor Yanukovych. I am arguing that Trump’s understanding of America’s role in the world aligns with Russia’s geostrategic interests; that his critique of American democracy is in accord with the Kremlin’s critique of American democracy; and that he shares numerous ideological and dispositional proclivities with Putin—for one thing, an obsession with the sort of “strength” often associated with dictators. Trump is making it clear that, as president, he would allow Russia to advance its hegemonic interests across Europe and the Middle East. His election would immediately trigger a wave of global instability—much worse than anything we are seeing today—because America’s allies understand that Trump would likely dismantle the post-World War II U.S.-created international order. Many of these countries, feeling abandoned, would likely pursue nuclear weapons programs on their own, leading to a nightmare of proliferation.
In his speech to the Republican National Convention, the presidential nominee revealed a deeply flawed political strategy.
Donald Trump’s supporters yearn for the country as it was and fear the country as it is. Tonight’s powerfully dystopian Trump nomination acceptance address will touch them at their deepest emotional core. It will ignite a passionate spasm of assent from those many, many Americans—mostly but not exclusively white, mostly but not exclusively less affluent and educated—who experience today as worse than yesterday, and anticipate a tomorrow worse than today.
Don’t think it won’t work. It will work. The speech will be viewed and viewed again, on cable news and social media. The travails and troubles of this dysfunctional convention will recede, even if their implications and consequences linger. Trump’s poll numbers will probably rise. Small-dollar donations will surely flow. Many wavering Republicans will come home—even if the home to which they now return has changed in ways that render it almost indistinguishable from the dwelling it used to be.
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.”
This week, the co-author of Donald Trump’s autobiography said in The New Yorker that if he were writing The Art of the Deal today, it would be a very different book with a very different title: The Sociopath.
To title a person’s life story with that label is a serious accusation, and one worth considering. The stakes are high. Tony Schwartz, the writer of the best-selling book, said that he “genuinely believe[s] that if Trump wins and gets the nuclear codes, there is an excellent possibility it will lead to the end of civilization.” In that light, Schwartz said he feels “deep remorse” at having “put lipstick on a pig.”
That seemed to me to be something of a contradiction to the charge of sociopathy, as pigs have been found to show signs of empathy. If you call a pig by name, it will come and play with you, reciprocating affection like a dog. So which is it, pig or sociopath?
In a week full of political propaganda, here's messaging done delightfully.
In a segment for James Corden’s “Carpool Karaoke”series that aired last night, Michelle Obama told the late-night host that this was one of the only times she’s been near the steering wheel of an automobile since arriving at the White House: “I’ve been in a car maybe months ago with my daughter who learned to drive, and we rocked out with her. But that was the only time in seven and a half years that I’ve been in the passenger seat, listening to music, rocking out like this.”
It’s one little anecdote that does so much: remind of how long we’ve all lived with this first family, of the isolating conditions they exist in, and also of their relatability as parents, as teenagers, and as people who love belting Beyoncé on their commute. The exchange also provides a near metaphor for what Michelle Obama has done with this instantly viral Late Late Show segment. She’s technically in the passenger seat, but really, she’s driving the car.