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."
We're all going to die and we all know it. This can be both a burden and a blessing.
In the heart of every parent lives the tightly coiled nightmare that his child will die. It might spring at logical times—when a toddler runs into the street, say—or it might sneak up in quieter moments. The fear is a helpful evolutionary motivation for parents to protect their children, but it's haunting nonetheless.
The ancient Stoic philosopher Epictetus advised parents to indulge that fear. “What harm is it, just when you are kissing your little child, to say: Tomorrow you will die?”he wrote in his Discourses.
Some might say Epictetus was an asshole. William Irvine thinks he was on to something.
“The Stoics had the insight that the prospect of death can actually make our lives much happier than they would otherwise be,” he says. “You’re supposed to allow yourself to have a flickering thought that someday you’re going to die, and someday the people you love are going to die. I’ve tried it, and it’s incredibly powerful. Well, I am a 21st-century practicing Stoic.”
Can a political system be democratically legitimate without being democratic?
The flaws in China’s political system are obvious. The government doesn’t even make a pretense of holding national elections and punishes those who openly call for multiparty rule. The press is heavily censored and the Internet is blocked. Top leaders are unconstrained by the rule of law. Even more worrisome, repression has been ramped up since Xi Jinping took power in 2012, suggesting that the regime is increasingly worried about its legitimacy.
Some China experts—most recently David Shambaugh of George Washington University—interpret these ominous signs as evidence that the Chinese political system is on the verge of collapse. But such an outcome is highly unlikely in the near future. The Communist Party is firmly in power, its top leader is popular, and no political alternative currently claims widespread support. And what would happen if the Party’s power did indeed crumble? The most likely result, in my view, would be rule by a populist strongman backed by elements of the country’s security and military forces. The new ruler might seek to buttress his legitimacy by launching military adventures abroad. President Xi would look tame by comparison.
Some spoiler-y speculation on the final three episodes
With only three episodes left to go, Game of Thrones looks as though it once again has a lot of ground to cover before wrapping up a season. And so, for the curious and impatient among you, I’ll do my best to offer some quasi-informed speculation about what we might reasonably expect in these final weeks.
Note: I haven’t seen any of the remaining episodes, but I have read the books. The first five items below are spoiler-y, but the predictions in them do not derive from the George R. R. Martin novels. Rather, they’re guesswork based on what’s already happened on the show and on tidbits scattered across the web: a behind-the-scenes photo here, a close-read of a trailer there. (They could all, of course, turn out to be completely wrong.) The last four items, however, are based at least in part on events that take place in A Feast for Crows and A Dance with Dragons, so non-book-readers may want to skip them. And obviously anyone, book-reader or not, who’d prefer to go into these final episodes without preconceptions—who doesn’t want to know at least some of what will (probably) happen—should stop reading now.
Fresh from his breakout performance as Martin Luther King Jr. in 2014’s Selma, the actor discusses his radically different role in HBO’s chilling one-man film Nightingale.
Nightingale poses a challenge to its viewers from its opening scene on. Protagonist Peter Snowden (David Oyelowo) has done a terrible thing—only hints of the aftermath can be glimpsed on screen—and the audience is trapped in his house with him. The film, which premieres on HBO Friday, is an audacious one-man show—a series of deluded, sometimes charming, often tragic, occasionally frightening monologues delivered by a troubled veteran clearly in the midst of a dissociative crisis. Peter works in a menial job and lives with his mother at home, where Nightingale is entirely set, but, as he repeatedly states, his “circumstances have changed” in horrifying fashion.
People look to Amy Schumer and her fellow jokers not just to make fun of the world, but to make sense of it. And maybe even to help fix it.
This week, in a much-anticipated sketch on her Comedy Central show, Amy Schumer staged a trial of Bill Cosby in “the court of public opinion.” Schumer—her character, at any rate—played the role of the defense. “Let’s remind ourselves what’s at stake here,” she argued to the jury. “If convicted, the next time you put on a rerun of The Cosby Show you may wince a little. Might feel a little pang. And none of us deserve that. We don’t deserve to feel that pang.”
Her conclusion? “We deserve to dance like no one’s watching, and watch like no one’s raping.”
Ooof. This is the kind of thing that gets Inside Amy Schumer referred to as “the most feminist show on television,” and her act in general called, in a phrase that reveals as much about her craft as about Schumer herself, “comedy with a message.” But while Schumer’s work is operating at the vanguard of popular comedy, it’s also in line with the work being done by her fellow performers: jokes that tend to treat humor not just as an end in itself, but as a vehicle for making a point. Watch like no one’s raping.
The Islamic State is no mere collection of psychopaths. It is a religious group with carefully considered beliefs, among them that it is a key agent of the coming apocalypse. Here’s what that means for its strategy—and for how to stop it.
What is the Islamic State?
Where did it come from, and what are its intentions? The simplicity of these questions can be deceiving, and few Western leaders seem to know the answers. In December, The New York Times published confidential comments by Major General Michael K. Nagata, the Special Operations commander for the United States in the Middle East, admitting that he had hardly begun figuring out the Islamic State’s appeal. “We have not defeated the idea,” he said. “We do not even understand the idea.” In the past year, President Obama has referred to the Islamic State, variously, as “not Islamic” and as al-Qaeda’s “jayvee team,” statements that reflected confusion about the group, and may have contributed to significant strategic errors.
The former speaker of the House is charged with lying to federal agents and evading financial reporting requirements, reportedly while attempting to conceal past sexual misconduct.
Updated on May 29, 2015, at 4:05 p.m.
Former House Speaker Dennis Hastert has been indicted on charges of lying to FBI agents and evading federal financial-reporting requirements, reportedly while paying a man to cover up past sexual misconduct.
Hastert, an Illinois Republican, was speaker from 1999 to 2007. BuzzFeed’s John Stanton notes that there were several high-profile congressional scandals in those years. Illinois is also a notorious hotbed for political corruption, as Roland Burris, Rod Blagojevich, George Ryan, and Jesse Jackson Jr. can attest.
But Hastert’s indictment seems to involve a darker story than political corruption. In or about 2010, according to the indictment, Hastert—a former high-school teacher and coach—met with an unnamed individual from Yorkville, Hastert’s hometown. They “discussed past misconduct by defendant against Individual A that had occurred years earlier.” In effect, Hastert fell victim to blackmail, the indictment alleges: He “agreed to provide Individual A $3.5 million in order to compensate for and conceal his prior misconduct against Individual A.” (Since leaving the House, Hastert has become a highly paid lobbyist.)
The danger of uploading one’s consciousness to a computer without a suicide switch
Imagine a supercomputer so advanced that it could hold the contents of a human brain. The Google engineer Ray Kurzweil famously believes that this will be possible by 2045. Organized technologists are seeking to transfer human personalities to non-biological carriers, “extending life, including to the point of immortality.” My gut says that they’ll never get there. But say I’m wrong. Were it possible, would you upload the contents of your brain to a computer before death, extending your conscious moments on this earth indefinitely? Or would you die as your ancestors did, passing into nothingness or an unknown beyond human comprehension?
The promise of a radically extended lifespan, or even immortality, would tempt many. But it seems to me that they’d be risking something very much like hell on earth.
Caves and tunnels have always been part of human life.
Caves and tunnels have always been part of human life. We've grown more adept at shaping these underground shelters and passages over the millennia, and today we dig for hundreds of reasons. We excavate to find both literal and cultural treasures, digging mines and unearthing archaeological discoveries. We use caverns for stable storage, for entertainment, and for an effective shelter from natural and man-made disasters. And as the planet's surface becomes ever more crowded, and national borders are closed, tunnels provide pathways for our vehicles and for smugglers of every kind. Collected below are more recent subterranean scenes from around the world.
An activist has made it so in France. Could he take his campaign global?
In 2010, U.S. supermarkets and grocery stores threw out 43 billion pounds, or $46.7 billion worth, of food, according to the U.S. Department of Agriculture (USDA). But if Arash Derambarsh had his way, that number would be zero. His goals are ambitious, but then again the municipal councilor from Courbevoie, France did manage to get a law passed in France last week that would accomplish just that.
The law bans supermarkets in France from discarding or destroying unsold food. According to Salon’s Lindsay Abrams, the law mandates that all unsold but edible food should be donated to charities for immediate distribution to the poor. Food that is unsafe to eat is to be donated to farms for agricultural purposes. Supermarkets that exceed a certain square footage are required to sign contacts with charities by July 2016; penalties for failing to do so include fines of up to roughly $81,600 or two years in prison. The legislation is one of the world’s first attempts to address the twin problems of food waste and hunger in this manner.