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."
According to Arthur, just a few months later, all 60 members of a committee selected by the American Dialect Society voted to google 2002’s most useful new word. Merriam-Webster and the Oxford English Dictionary would soon note the coinage. By 2006, Google’s lawyers—fearful of seeing the company’s name brand watered down to the trademark mushiness of kleenex—wrote a post for the company blog outlining when and when not to google should be used.
From the “400-pound” hacker to Alicia Machado, the candidate’s denigration of fat people has a long tradition—but may be a liability.
One of the odder moments of Monday’s presidential debate came when Donald Trump speculated that the DNC had been hacked not by Russia but by “someone sitting on their bed that weighs 400 pounds.” He was trying to suggest the crime had been committed by someone unaffiliated with a government—but why bring up fatness?
Weight seems to be one of Trump’s preoccupations. The debate and its fallout highlighted how he publicly ridiculed the Miss Universe winner Alicia Machado as “Miss Piggy” and an “eating machine,” and how he called Rosie O’Donnell a “fat pig” with “a fat, ugly face” (“I think everyone would agree that she deserves it and nobody feels sorry for her,” he said onstage Monday). He also recently poked fun at his ally Chris Christie’s weight-loss struggles and called out a protestor as “seriously overweight.” And when he was host of The Apprentice, he insisted on keeping a “funny fat guy” on the show, according to one of its producers.
The biggest threat to the Republican nominee is not his poor performance in the debate, but his reaction to it: blaming microphones, insisting he won, and doubling down on gaffes.
Debates seldom make a great deal of difference to the outcome of the election. Mitt Romney’s dominating performance in the first debate four years ago? Didn’t stop Obama’s reelection. Gerald Ford’s “no domination of Eastern Europe” gaffe in 1976? He rose after it.
Sure, it’s better to win than to lose, but the historical record is a good reminder of why Hillary Clinton’s strong performance in Monday’s debate could have a limited effect on the election’s outcome. If it does have a lasting impact, however, it will likely be due not to what happened on stage at Hofstra University, but due to Donald Trump’s hectic, frenetic crisis-communications strategy.
This is a pattern amply seen before in the election: Trump gets caught in a tight spot, and rather de-escalate, he tends to take out the bellows and fan the flames as much as he can. Time and again, he has managed to overtake a news cycle (and often overshadow bad news about Clinton) thanks to bad crisis management. It’s what he did in his tiff with Khizr and Ghazala Khan, and so far it’s his post-debate strategy, too.
In a unique, home-spun experiment, researchers found that centripetal force could help people pass kidney stones—before they become a serious health-care cost.
East Lansing, Michigan, becomes a ghost town during spring break. Families head south, often to the theme parks in Orlando. A week later, the Midwesterners return sunburned and bereft of disposable income, and, urological surgeon David Wartinger noticed, some also come home with fewer kidney stones.
Wartinger is a professor emeritus at Michigan State, where he has dealt for decades with the scourge of kidney stones, which affect around one in 10 people at some point in life. Most are small, and they pass through us without issue. But many linger in our kidneys and grow, sending hundreds of thousands of people to emergency rooms and costing around $3.8 billion every year in treatment and extraction. The pain of passing a larger stone is often compared to child birth.
In North Carolina, the Democratic candidate basked in her debate victory. As for her supporters, they’re feeling better, but they’re not ready to exhale.
RALEIGH, N.C.— "Did anybody see that debate last night? Ooooh yes," Hillary Clinton said, her first words after striding confidently out on stage at Wake Technical Community College Tuesday afternoon.
As a capacity crowd cheered, she added, "One down, two to go."
Celebration and relief added to the thick humidity of late summerat Clinton’s event inNorth Carolina. Post-debate analysis is in that awkward in-between state, after the pundits have rendered their verdicts and before high-quality polling has measured the nation’s response. But the Democratic nominee seemed sure that she was the victor.
It was Clinton’s first event after the first presidential debate Monday evening in Hempstead, New York. One sign of her confidence coming out of that encounter: As I approached the rally, a man asked for a hand loading a heavy box into his car. He was the teleprompter man, he said, but when he arrived in Raleigh, he’d been told that Clinton had decided to do without the prompter. He was turning around and heading back to Washington, D.C.
The films touted for consideration this year include prestige projects like Martin Scorsese’s Silence and festival hits like Barry Jenkins’s Moonlight.
With the main film festivals of the fall (Telluride, Venice, and Toronto) now concluded, and Martin Scorsese finally confirming that his much-anticipated drama Silence will come out at the end of the year, the next three months will bring a calendar loaded with prestige releases. Among them are films that better reflect the wide range of faces and voices in America (and around the world), which have recently been severely under-represented on Oscar night. Audiences and critics will be paying especially close attention to the works and actors the Academy chooses to recognize, after the awards were condemned this year for nominating only white performers two years in a row.
The question, as always, is which films will be able to stand out once studios begin their awards campaigns in earnest. A lot can happen in a few months; after all, the season has already seen its earliest anointed front-runner practically disappear from the race. The former Best Picture favorite was the big story out of Sundance: The Birth of a Nation(October 7), a searing depiction of Nat Turner’s 1831 slave rebellion in Virginia written and directed by Nate Parker. The film won the festival’s Grand Jury Prize just as the conversation over the largely white Oscar nominations was at its loudest. The movie was acquired by Fox Searchlight for a record $17.5 million, with the studio promising a huge publicity campaign in the fall to help push it for awards contention.
For decades, the candidate has willfully inflicted pain and humiliation.
Donald J. Trump has a cruel streak. He willfully causes pain and distress to others. And he repeats this public behavior so frequently that it’s fair to call it a character trait. Any single example would be off-putting but forgivable. Being shown many examples across many years should make any decent person recoil in disgust.
Judge for yourself if these examples qualify.
* * *
In national politics, harsh attacks are to be expected. I certainly don’t fault Trump for calling Hillary Clinton dishonest, or wrongheaded, or possessed of bad judgment, even if it’s a jarring departure from the glowing compliments that he used to pay her.
But even in a realm where the harshest critiques are part of the civic process, Trump crossed a line this week when he declared his intention to invite Gennifer Flowers to today’s presidential debate. What kind of man invites a husband’s former mistress to an event to taunt his wife? Trump managed to launch an attack that couldn’t be less relevant to his opponent’s qualifications or more personally cruel. His campaign and his running-mate later said that it was all a big joke. No matter. Whether in earnest or in jest, Trump showed his tendency to humiliate others.
A new study looks at rates of lethal violence across a thousand species to better understand the evolutionary origins of humanity’s own inhumanity.
Which mammal is most likely to be murdered by its own kind? It’s certainly not humans—not even close. Nor is it a top predator like the grey wolf or lion, although those at least are #11 and #9 in the league table of murdery mammals. No, according to a study led by José María Gómez from the University of Granada, the top spot goes to… the meerkat. These endearing black-masked creatures might be famous for their cooperative ways, but they kill each other at a rate that makes man’s inhumanity to man look meek. Almost one in five meerkats, mostly youngsters, lose their lives at the paws and jaws of their peers.
Gómez’s study is the first thorough survey of violence in the mammal world, collating data on more than a thousand species. It clearly shows that we humans are not alone in our capacity to kill each other. Our closest relatives, the chimpanzees, have been known to wage brutal war, but even apparently peaceful creatures take each other’s lives. When ranked according to their rates of lethal violence, ground squirrels, wild horses, gazelle, and deer all feature in the top 50. So do long-tailed chinchillas, which kill each other more frequently than tigers and bears do.
Congress delivered a historic rebuke to the administration on Wednesday by overriding Obama’s veto.
CIA Director John Brennan warned against the national security risks of legislation that would allow families of victims of the September 11, 2001 terror attacks to sue the government of Saudi Arabia on Wednesday.
“I think the legislation is badly misguided and doesn’t take into account the negative impact on U.S. national security,” Brennan told Jeffrey Goldberg at the Washington Ideas Forum presented by The Atlantic and the Aspen Institute. Brennan added: “We all recognize that the emotions associated with 9/11 are still quite palpable [and] …. the victims’ families are still seeking justices, but the 9/11 commission report said that there was no evidence that the Saudi government as an institution or senior Saudi officials, individually, were responsible for the 9/11 attack.”