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."
“People skills” are almost always assumed to be a good thing. Search employment ads and you will find them listed as a qualification for a startling array of jobs, including Applebee’s host, weight-loss specialist, CEO, shoe salesperson, and (no joke) animal-care coordinator. The notion that people smarts might help you succeed got a boost a quarter century ago, when the phrase emotional intelligence, or EI, entered the mainstream. Coined in a 1990 study, the term was popularized by Daniel Goleman’s 1995 book . Since then, scores of researchers have shown how being in touch with feelings—both your own and other people’s—gives you an edge: compared with people who have average EI, those with high EI do better at work, have fewer health problems,and report greater life satisfaction.
Orr:Wait a minute. There’s a royal wedding—and nobody dies a horrible death? A man is beheaded—and we can all agree that it was for the best? What the hell show am I watching? I came here for Game of Thrones, baby, not Wizards of Waverly Place.
I kid, of course. Given David Benioff and D.B. Weiss’s tendency to take George R. R. Martin’s material and render it even more bloody than it already was, I’m actually mildly relieved that they didn’t throw in a random homicide just to spice up the nuptials of Margaery and young Tommen, First of His Name.
Take a walk along West Florissant Avenue, in Ferguson, Missouri. Head south of the burned-out Quik Trip and the famous McDonalds, south of the intersection with Chambers, south almost to the city limit, to the corner of Ferguson Avenue and West Florissant. There, last August, Emerson Electric announced third-quarter sales of $6.3 billion. Just over half a mile to the northeast, four days later, Officer Darren Wilson killed Michael Brown. The 12 shots fired by Officer Wilson were probably audible in the company lunchroom.
Outwardly, at least, the City of Ferguson would appear to occupy an enviable position. It is home to a Fortune 500 firm. It has successfully revitalized a commercial corridor through its downtown. It hosts an office park filled with corporate tenants. Its coffers should be overflowing with tax dollars.
Freddie Gray's death on April 19 leaves many unanswered questions. But it is clear that when Gray was arrested in West Baltimore on the morning of April 12, he was struggling to walk. By the time he arrived at the police station a half hour later, he was unable to breathe or talk, suffering from wounds that would kill him.*
Gray died Sunday from spinal injuries. Baltimore authorities say they're investigating how the 25-year-old was hurt—a somewhat perverse notion, given that it was while he was in police custody, and hidden from public view, that he apparently suffered injury. How it happened remains unknown. It's even difficult to understand why officers arrested Gray in the first place. But with protestors taking to the streets of Baltimore since Gray's death on Sunday, the incident falls into a line of highly publicized, fatal encounters between black men and the police. Meanwhile, on Tuesday, a reserve sheriff's deputy in Tulsa, Oklahoma, pleaded not guilty to a second-degree manslaughter charge in the death of a man he shot. The deputy says the shooting happened while he was trying to tase the man. Black men dying at the hands of the police is of course nothing new, but the nation is now paying attention and getting outraged.
After a five-month delay, Loretta Lynch made history last week. On Thursday, the Senate confirmed Lynch as the next U.S. attorney general, the first African American woman ever to hold this Cabinet position. Her long-stalled nomination sometimes seemed in doubt, held hostage to partisan jockeying between Democrats and Republicans. But one political bloc never gave up, relentlessly rallying its support behind Lynch: the black sorority.
During her initial hearing, the seats behind Lynch were filled with more than two dozen of her Delta Sigma Theta Sorority sisters arrayed in crimson-and-cream blazers and blouses, ensuring their visibility on the national stage. These Delta women—U.S. Representatives Marcia Fudge and Joyce Beatty among them—were there to lend moral support and show the committee that they meant business. The Deltas were not alone. The Lynch nomination also drew support from congressional representatives from other black sororities: Alpha Kappa Alpha members Terri Sewell and Sheila Jackson Lee took to the House floor to advocate for a vote while Sigma Gamma Rho members Corinne Brown and Robin Kelly and Zeta Phi Beta member Donna Edwards used social media and press conferences to campaign on Lynch’s behalf.
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.
At a large distribution center located north of Boston, a robot lifts a shelf holding merchandise and navigates it through the warehouse to the workstation of an employee who then picks the item needed for an order and places it in a shipping box. Incoming orders are processed by a computer that sends picking requests to sixty-nine robots. Then, the robots deliver storage units to roughly a hundred workers, saving the workers the task of walking through the warehouse to find the items. In other distribution centers, this is work that warehouse workers do.
The distribution center, run by Quiet Logistics—a company that fills orders for sellers of premium-branded apparel, is featured in the60 Minutes episode “Are Robots Hurting Job Growth?” In the segment, Steve Kroft poses the following question to Bruce Welty, the CEO of Quiet Logistics: "If you had to replace the robots with people, how many people would you have to hire?" Welty estimates that he would have to hire one and a half people for every robot, and that the robots are saving him a lot of money.
Hours after a major earthquake wreaked havoc across his country, Nepali Information Minister Minendra Rijal appeared at a news conference on Saturday to announce that schools would be closed for the next five days. "We never imagined we'd face such devastation," he said.
But for geologists, Saturday's disaster—which has claimed over 2,400 lives—was sadly predictable.
"Physically and geologically what happened is exactly what we thought would happen," James Jackson, head of the earth-sciences department at the University of Cambridge, told the Associated Press.
Blessed with stunning natural scenery, Nepal is a popular tourist destination that attracts hundreds of thousands of travelers each year. But the source of the country's beauty is what makes it particularly vulnerable to earthquakes. Much of Nepal's population lives in a valley beneath the Himalayas, a mountain range formed by collisions between the Indian and Central Asian tectonic plates. These collisions—which occur when the Indian plate slides underneath its much larger neighbor—are what cause earthquakes. According to The Washington Post, a chunk of the earth measuring 75 by 37 miles shifted 10 feet in 30 seconds on Saturday, destroying much of what lay atop the surface.
In 1979, almost a year into the papacy of John Paul II, a novel called The Vicar of Christ spent 13 weeks on the New York Times best-seller list. The work of a Princeton legal scholar, Walter F. Murphy, it featured an unlikely papal candidate named Declan Walsh—first a war hero, then a United States Supreme Court justice, and then (after an affair and his wife’s untimely death) a monk—who is summoned to the throne of Saint Peter by a deadlocked, desperate conclave.
Once elevated, Walsh takes the name Francesco—that is, Francis—and sets about using the office in extraordinary ways. He launches a global crusade against hunger, staffed by Catholic youth and funded by the sale of Vatican treasures. He intervenes repeatedly in world conflicts, at one point flying into Tel Aviv during an Arab bombing campaign. He lays plans to gradually reverse the Church’s teachings on contraception and clerical celibacy, and banishes conservative cardinals to monastic life when they plot against him. He flirts with the Arian heresy, which doubted Jesus’s full divinity, and he embraces Quaker-style religious pacifism, arguing that just-war theory is out of date in an age of nuclear arms and total war. (This last move eventually gets him assassinated, probably by one of the governments threatened by his quest for peace.)
My grandfather broke his hip at age 87. At the time, he lived with my grandmother in western Massachusetts in a beautiful house they’d built themselves abutting a farm. At 88, she was as “with it” as someone decades her junior, and she was determined to help him continue to live at home, where he could listen to classical music in his sunny study, or gaze at the sheep that sometimes grazed outside his window.
He went to a nursing home for short-term rehab right after the accident, and it was nightmarish, she told me. He was trapped in a room with patients who would be there for the rest of their lives, which depressed him. Nurses gave him his medication on an erratic schedule, not necessarily prioritizing his health. My grandmother decided he would do better at home.