If you need laser eye surgery in the state of Kentucky, or a little cosmetic work around the eyelids, it now behooves you to ask your prospective surgeon the following question before signing the operative consent form:
"Say doc, did you go to medical school?"
Kentucky joined the company of Oklahoma last week as the second state to conflate optometrists and ophthalmologists. Only ophthalmologists are the sort of doctors who graduated from medical school, did an internship, completed a three-year residency in eye surgery, possibly a fellowship after that, and have achieved and maintained national board certification through a program of lifelong learning in their specialty.
Optometry schools (four-year programs focused on optics to prescribe glasses and contacts and the diagnosis and management of certain eye-related diseases) have a tough application process too, and many of the same students going into optometry could have chosen medicine. But nobody ever really faces a clear-cut choice of going into optometry or ophthalmology. Even if you do exceedingly well in medical school, you could easily miss out on an ophthalmology residency slot. Ophthalmology is among the most selective specializations in medicine. Yet despite having earned a reputation within medical science as one of its most advanced and storied fields, these days ophthalmology is challenged with its branding, of all things. Perhaps it's the funny spelling?
Nationwide, about 30 percent of consumers don't know the difference between the two types of eye doctors, according to a survey conducted by the National Consumer's League (the NCL designed the study independently, then applied for and received unrestricted funding from the American Academy of Ophthalmology, which did not commission the study). Ninety-five percent of the 600 Americans surveyed wanted an M.D. wielding the scalpel or the laser if they needed eye surgery. Regular everyday people seem to sense that the eyes are part of the body, that serious disease might have something to do with the whole, and that at the very least, you might want a full-service clinician involved if something becomes complicated enough for an invasive procedure.
Proponents of optometry's expansion argued that having optometrists perform in-office laser eye procedures, inject medications into eyes, and cut out "lumps and bumps" around the eyes increases health care access for Kentucky's rural citizens (Kentucky's Medicaid program can spend $150 in transportation credits for a $50 ophthalmology check-up). Optometrists outnumber ophthalmologists by a ration of four to one and can be found in most Kentucky counties.
But while you could easily be forgiven for imagining that Kentucky's leadership must now be hot on the trail of other ways to foster health care accessibility, like chiropractic spine surgery or cosmetic surgery parlors, do not expect the complete democratization of medicine until back adjusters and cosmetologists can pay to play with the same skill as optometrists. Mistaking optometry for ophthalmology was no Mr. Magoo moment.
"If you go back and look at our involvement in politics in terms of contributions, we've always been involved," says Dr. Ian Benjamin Gaddie, president-elect of the Kentucky Optometric Association. "We work hand-in-hand in the community with these people and that makes a huge difference."
Efforts included lobbying state legislators while they were immobilized in the optometric examining chair, reports indicate.
"In many states it's just how the stars line up, and how your luck goes as you run the gamut through the political process," Dr. Gaddie told me.
The Louisville Courier-Journal's Frankfort bureau chief Tom Loftus followed the blue grass stardust:
"Kentucky optometrists and their political action committee have given campaign money to 137 of the 138 members of the state legislature and Gov. Steve Beshear, contributing more than $400,000 as they push for a bill to expand their practices.
Members of the Kentucky Optometric Association and its PAC have given at least $327,650 to legislative candidates in the last two years alone and have hired 18 lobbyists to help them make their case.
They also gave a total of at least $74,000 more to Beshear's re-election campaign, the Republican gubernatorial campaign of Senate President David Williams and the House and Senate political caucuses."
Optometry waged state-by-state expansion of practice battles for four decades on its way to where the profession stands now, which is increasingly nebulous. The American Academy of Ophthalmology and the American Medical Association have challenged optometry every step as optometry blurs its boundaries with medicine. A patchwork quilt of legislation around the country variably delineates optometric practice. Now two patches have little pockets for scalpels and lasers.
For optometrists, serving us as the "primary health care professional for the eye" means what the state says it does, and that can vary widely, creating confusion among patients and the rest of the medical world. Citing how in some states optometrists must obtain certifications for medications they have no intention of ever using, the American Society of Health-System Pharmacists pointed to optometrist licensure as an example to avoid.
Optometrists have been dilating eyes since the 1970s to better diagnose eye diseases, and have been using local medications in most states since the 1980s. They no longer face opposition from ophthalmology on these fronts. "We draw the philosophical line in the sand with surgery," says Dr. David Parke, chief executive officer of the American Academy of Ophthalmology.
Ophthalmologists have successfully fought back in 25 other state battles where optometrists asked legislatures to let them perform surgery, he says, by pointing out the difference in quality of training and management of adverse events.
While chair of the University of Oklahoma's Department of Ophthalmology for 17 years, Dr. Parke dealt with the aftermath of upgraded optometric licensure in that state. He says the problems he saw were the result of "not knowing what you don't know."
Dr. Parke's experience included treating a man whose "skin tag" was excised by an optometrist. Nine months later the patient came to the university medical center with an invasive, substantive squamous cell carcinoma that required a massive reconstructive surgery. "We asked the patient, 'Why'd you let him do that?' He replied, 'Well he's a doctor, he had on a white coat and he said he could.'"
In another case, an elderly patient with severe end-stage glaucoma could only be controlled surgically through a technique called filtering blebs. "She went to an optometrist who said to the patient, 'Mrs. Jones, you have cysts on your eyes, I should take care of those now,' and he proceeded to excise them, completely undoing the surgery."
"In the end it scares me, quite frankly," says Dr. Parke.
The most common laser procedure Kentucky optometrists will perform involves using a YAG laser to clear a membrane that becomes cloudy in some patients after lens replacement surgery (it's something ophthalmologists do as needed on post-cataract surgery follow-up appointments). The procedure may take only 20 minutes to learn and looks as simple as a video game. But complications can occur.
"You can be a pilot, and say, 'I'm just going to fly in good weather' -- but you never know when it's gonna get dark, or when the storm's gonna come up," says Dr. Woodford Van Meter, president of the Kentucky Academy of Eye Physicians and Surgeons. "You can go get an amateur pilot's license, but that doesn't mean you should fly a jetliner full of passengers down to Florida."
But ophthalmologists can only convey their concerns when they're given enough time. By the immaculate design of 18 lobbyists, the ophthalmologists knew about the Kentucky bill just 12 hours before it entered a Senate committee (bypassing a customary 72-hour holding period), and sailed through that committee to the Senate floor the next day. The whole process, from the bill's first public posting to the Governor signing it into law, took 17 days, bypassing hundreds of other bills filed well before it. "It was a juggernaut. It was an advancing force that seemed to crush everything under its path," Tom Loftus said on the KET program Comment on Kentucky.
Dr. Van Meter says he and his colleagues got 10 minutes total to make their case at an informational hearing put together at the last minute in the Kentucky Senate.
"The people pushing the bill to me looked like your dog when you come into the kitchen and he's taken a piece of meat of your plate," Dr. Van Meter told me. "He just looks guilty as sin, but he's sitting there smiling with big eyes like nothing in the world ever happened."
The bill itself looks like a rush job. It even includes an anatomical error. It prohibits optometrists from injecting into the posterior chamber of the eye (nobody can, it's too small a space). Presumably that line meant to state that optometrists cannot inject into the posterior segment of the eye, which includes the vitreous. Because of the sloppy writing, now optometrists can inject into the posterior segment, using drugs like Lucentis to treat macular degeneration. The bill also excludes optometrists from performing two common excimer laser corrective vision procedures, LASIK and PRK, but leaves out another common procedure, LASEK.
Dr. Ben Gaddie admits the LASEK loophole exists, but he expects the optometry board won't allow excimer laser procedures at all, following the spirit of the legislation if not its wording. However, he's not on the optometry board.
Dr. Van Meter and other state ophthalmology leaders sat down with Kentucky's governor to make their case as he weighed whether to sign the bill that had arrived on his desk with such urgency. They were a little flummoxed when it became apparent the governor had little issue with the idea that providers who didn't go to medical school would be doing surgery. "He seemed to think that was okay," Dr. Van Meter observes.
I asked the governor, who was on the road attending the National Governor's Association Winter Meeting in D.C. this weekend, whether he was now pioneering the way for other states in redefining optometry. He's making no such stand. Beshear based his decision "solely on what is best for the people of Kentucky. Under that framework, improving access to health care of all kinds is a priority for Kentuckians. Other states must make their own determinations for what is best for their citizens," he wrote in an email.
Elaborating on the access issue, Beshear wrote, "there are fewer ophthamologists in Kentucky than optometrists, and at times, it may be easier for residents (especially in rural areas) to get access to an optometrist for needed eye care. There will be times when citizens will require the services of an ophthalmologist; however, this legislation will allow Kentuckians to have more options in accessing proper eye care."
Naturally I wanted to know whether the governor would choose the care of an ophthalmologist or an optometrist should he need an eye surgery now in the optometry's purview. Maybe he'll simply pick the geographically closest provider, like he expects the disadvantaged Appalachian citizens of his state will do? He didn't answer that one.
What's optometry's end game, if the field sees itself as the primary care providers for the eye? "It's hard for me to fathom that the end goal of the organized profession of optometry is to go in and do routine intraocular surgery like retinal disease or cataract surgery or incisional glaucoma surgery," says Dr. Ben Gaddie. He believes that the minor surgical procedures with scalpels and lasers Kentucky now allows fit into the "primary care" mold.
It sure sounds specialized to me. The eye is part of the central nervous system. I don't know too many primary care docs who do a little bit of neurosurgery or plastic surgery on the side. There's a reason the rest of medicine organizes itself into cardiologists and cardiovascular surgeons, neurologists and neurosurgeons, and so on. There's a reason you want a surgeon to do surgery. They do a lot, and they do it well. It's worth a little drive.
"I give the optometrists an A+ in politics," says Dr. Parke of the ophthalmology association. "I may give them an F in being an effective advocate for patient safety and quality of care."
A history of the first African American White House—and of what came next
In the waning days of President Barack Obama’s administration, he and his wife, Michelle, hosted a farewell party, the full import of which no one could then grasp. It was late October, Friday the 21st, and the president had spent many of the previous weeks, as he would spend the two subsequent weeks, campaigning for the Democratic presidential nominee, Hillary Clinton. Things were looking up. Polls in the crucial states of Virginia and Pennsylvania showed Clinton with solid advantages. The formidable GOP strongholds of Georgia and Texas were said to be under threat. The moment seemed to buoy Obama. He had been light on his feet in these last few weeks, cracking jokes at the expense of Republican opponents and laughing off hecklers. At a rally in Orlando on October 28, he greeted a student who would be introducing him by dancing toward her and then noting that the song playing over the loudspeakers—the Gap Band’s “Outstanding”—was older than she was.
And the bright side of rising pessimism about the American Dream
Updated at 3 p.m. ET
One of the hallmarks of America’s supposed exceptionalism is its citizens’ extraordinary optimism. A 2014 study found that Americans were more likely to describe their day as "particularly good" than any rich European country. Nothing reflects this sunniness like the enduring parable of the American Dream, the idea that, only in America, even the poorest can transform their fortunes through hard work.
But there is a dark and deeply ironic element to American dreaminess. Americans are “too optimistic” about the odds of poor citizens getting richer “relative to actual mobility in the U.S.,” according to a new paper by the economists Alberto Alesina, Stefanie Stantcheva, and Edoardo Teso. As a result, Americans are less likely to support large federal anti-poverty programs—programs that would actually help the American Dream become reality for more people—since they believe that they are already living among throngs of Horatio Algers.
Unlike past presidents-elect, Donald Trump hasn’t expanded his support since the election. His belligerent attitude toward his critics may be one reason why.
Donald Trump always seems most grounded in chaos. He thrives on contradicting his aides, surprising his allies, disparaging his opponents. He revels in the tempest.
This combustible approach has touched a chord with his base of primarily non-college-educated and non-urban white voters who have felt eclipsed both economically and culturally and slighted by the nation’s leadership. But he will arrive at his inaugural Friday facing more resistance in public opinion than any newly elected president in the history of polling, and with lingering clouds over his legitimacy—symbolized by the surprisingly widespread House Democratic boycott of the ceremony. Trump’s agenda is polarizing enough, but the intensity of that opposition appears rooted even more in his relentless belligerence toward any critical voice or institution.
More clues that the Facebook founder is eyeing a run for office
There’s a long-running theory that Mark Zuckerberg has presidential aspirations. It makes sense to wonder. After all, if the civically engaged and ambitious billionaire leader of the most powerful media company on the planet wanted to take on a new challenge, why not try running a country? It’s not like he has many other opportunities for a promotion.
But only in recent weeks has a Zuckerberg run for the American presidency started to seem like a legitimate possibility. First there was his personal challenge for 2017: Zuckerberg’s aiming to visit and meet with people in all 50 states by the end of the year.
And not just that, but he framed the exercise in a way that sounds, well, political: “Going into this challenge, it seems we are at a turning point in history,” he wrote in a Facebook post. “For decades, technology and globalization have made us more productive and connected. This has created many benefits, but for a lot of people it has also made life more challenging. This has contributed to a greater sense of division than I have felt in my lifetime. We need to find a way to change the game so it works for everyone.”
This lack of discussion of civil-rights issues at the hearing was glaring, but it may be in line with DeVos’s advocacy of school vouchers and other school-choice programs in her home state of Michigan. As Kimberly Quick, a policy associate at the Century Foundation, notes, “Both historically and currently, voucher programs have served as a means for wealthier and white families to flee an increasingly diverse public school system, moving into largely unaccountable private schools that can exclude students based on a number of factors.”
The president-elect filled out his Cabinet on Thursday by nominating former Georgia Governor Sonny Perdue for agriculture secretary.
Updated on January 19, 2017
A day before his inauguration, President-elect Donald Trump has filled out his Cabinet.
Trump on Thursday morning announced the nomination of former Georgia Governor Sonny Perdue as secretary of agriculture, completing a search that took the duration of his presidential transition.
Perdue, who served as governor from 2003 to 2011, grew up on a farm in Georgia and earned a doctorate in veterinary medicine. “Sonny Perdue is going to accomplish great things as Secretary of Agriculture,” Trump said in a statement. “From growing up on a farm to being governor of a big agriculture state, he has spent his whole life understanding and solving the challenges our farmers face, and he is going to deliver big results for all Americans who earn their living off the land.”
“Trump is absolutely trying to attack our democratic institutions and to make the country more authoritarian,” one Democratic lawmaker warns.
A steadily growing number of congressional Democrats are refusing to attend Donald Trump’s inauguration, sending a message of resistance at the outset of Trump’s presidency. It’s less clear, however, what exactly that message is, and whether it will do the Democratic Party much good as it attempts to find its way in the Trump era.
The high-profile protest was galvanized by the president-elect’s rebuke of civil rights icon John Lewis as “all talk” and no action” over the weekend after the Georgia congressman said he does not view Trump “as a legitimate president” and did not plan to attend Trump’s inauguration. At the latest count, more than 60 Democrats in Congress have now announced they will not show up. Painting a bleak picture of what the country now faces, some Democrats warn that the incoming Trump administration could fundamentally erode American democracy.
For one thing, she’s never attended or taught at a public school.
Betsy DeVos is likely to be confirmed as the next secretary of education. There’s nothing unusual about the Senate supporting a president-elect’s choice to lead the U.S. Department of Education. But DeVos is a more controversial choice than nominees in recent memory.
At his hearing, the outgoing education secretary, John King, faced friendly questioning from the senators on the education committee in charge of moving nominations forward, including from the Republican chairman, Lamar Alexander. King’s predecessor, Arne Duncan, was confirmed in the Senate by a voice vote. It’s not just Democrats who have had easy confirmations, either. Both of George W. Bush’s education secretaries—Rod Paige and Margaret Spellings—were also confirmed by voice vote and received praise during their hearings from Republicans and Democrats alike.
For generations, American presidents have vowed to use their power to spread freedom around the globe. But the president-elect is set to break with that precedent.
Inaugural addresses are, in part, catechisms. The new president signals that he’ll take the country in a new direction. But he casts that new direction as consistent with old and cherished national principles, from which the country has strayed, and to which it must return.
Since Woodrow Wilson, and certainly Franklin Roosevelt, part of the catechism has been America’s mission to defend freedom around the world. For close to a century, incoming presidents have called American power a blessing from God, which the United States must use to assist the cause of liberty in other lands.
But this Friday, Trump may not say that. No president-elect in modern American history has talked less about America’s obligations to the rest of humanity. When it comes to foreign policy, Trump has two primary rhetorical modes. The first is transactional: America is being ripped off by other nations, and must cut better deals. The second is civilizational: America is part of the Judeo-Christian West, which is threatened by “radical Islam.” The former defines the world as a struggle between America and its trading partners. The latter defines the world as a struggle between civilizations. Neither mode suggests that promoting freedom for peoples of all nationalities, races, and religions serves America’s interest. Both are fundamentally zero-sum.
Curfews, sports, and understanding kids’ brain chemistry have all helped dramatically curb substance abuse in the country.
It’s a little before 3 p.m. on a sunny Friday afternoon and Laugardalur Park, near central Reykjavik, looks practically deserted. There’s an occasional adult with a stroller, but the park’s surrounded by apartment blocks and houses, and school’s out—so where are all the kids?
Walking with me are Gudberg Jónsson, a local psychologist, and Harvey Milkman, an American psychology professor who teaches for part of the year at Reykjavik University. Twenty years ago, says Gudberg, Icelandic teens were among the heaviest-drinking youths in Europe. “You couldn’t walk the streets in downtown Reykjavik on a Friday night because it felt unsafe,” adds Milkman. “There were hordes of teenagers getting in-your-face drunk.”