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."
On Saturday, the GOP dispensed with concern about keeping up appearances—and put long-simmering anger on display.
Perhaps the most haunting memory of the night will be the audience. Previous presidential debates have banned cheering and booing. Saturday night’s Republican debate in Greenville was marked by both. Permitted or not, the rowdy crowd ventilated its feelings without concern for how it looked or sounded to the viewers at home.
This unconcern for appearances was a Republican theme of the weekend. Hours before the debate opened, news broke that Supreme Court Justice Antonin Scalia had died. Candidates Ted Cruz and Marco Rubio promptly issued statements opining that any appointing any replacement should be left to the next president. It’s not unheard of for candidates to express emotive positions adopted for political advantage. But that same evening, Senate Majority Leader Mitch McConnell joined in, with a statement ruling out any Senate action on any Supreme Court nominee, no matter who it might be.
A profanity-filled new self-help book argues that life is kind of terrible, so you should value your actions over your emotions.
Put down the talking stick. Stop fruitlessly seeking "closure" with your peevish co-worker. And please, don't bother telling your spouse how annoying you find their tongue-clicking habit—sometimes honesty is less like a breath of fresh air and more like a fart. That’s the argument of Michael Bennett and Sarah Bennett, the father-daughter duo behind the new self-help book F*ck Feelings.
The elder Bennett is a psychiatrist and American Psychiatric Association distinguished fellow. His daughter is a comedy writer. Together, they provide a tough-love, irreverent take on “life's impossible problems.” The crux of their approach is that life is hard and negative emotions are part of it. The key is to see your “bullshit wishes” for just what they are (bullshit), and instead to pursue real, achievable goals.
The Republican frontrunner repudiated a long litany of party orthodoxies in a contentious debate—but will that hurt his candidacy, or help it?
Donald Trump blamed the Bush administration for failing to heed CIA warnings before 9/11; denounced the Iraq War for destabilizing the Middle East; defended the use of eminent domain; promised to save Social Security without trimming benefits; and credited Planned Parenthood for “wonderful things having to do with women's health.”
He’s fresh off a crushing victory in New Hampshire, and the prohibitive favorite in the polls in South Carolina. Will his flouting of Republican orthodoxy sink his chances—or is it his very willingness to embrace these heterodox stances that has fueled his rise?
Even his rivals no longer seem certain of the answer. Jeb Bush, at one point, called Trump “a man who insults his way to the nomination.” He sounded like a man ruing a race that has run away from him.
The staunchly Catholic U.S. Supreme Court justice was known for his acidly conservative opinions, but ultimately, he prioritized the Constitution over the Church.
“How can the Court possibly assert that ‘the First Amendment mandates governmental neutrality between … religion and nonreligion’?” the U.S. Supreme Court Justice Antonin Scalia wrote in 2005, arguing that two Kentucky counties should be able to display the Ten Commandments in their courthouses. “Who says so? Surely not the words of the Constitution.”
This moment, with Scalia’s trademark snark, nicely sums up the paradox of how his religious views influenced his Supreme Court career. The justice, who died Saturday, consistently argued that the United States is fundamentally religious, meaning that the government shouldn’t have to avoid religious displays—nativity scenes on public property, prayers at townhall meetings, and the like. His Roman Catholic faith often seemed to lurk in the background of his opinions, especially in cases involving abortion and homosexuality. But above all, he was committed to a literal, originalist interpretation of the Constitution, along with strict attention to the texts of federal and state laws. His views didn’t always align with those of the Church, and he didn’t always side with people making religious-freedom claims.
The current system for gaining entry to elite colleges discourages unique passions and deems many talented students ineligible.
March madness is almost here. No, I’m not referring to the college-basketball playoffs; I’m alluding to the anxious waiting of young people and their families of word about their fate from the highly selective colleges of America. And I’m talking as well about those who are about to venture forth on the ritualistic campus tours to determine where they will apply next fall. What few of these families realize is how broken the admission system is at these selective colleges.
At these institutions of higher learning, the goal is to “shape a class,” which involves trying to admit qualified and diverse students who will learn from each other as well as from their experiences in the classroom. These are the students who have the greatest potential to use their education in productive ways and to contribute to their own well-being and to the needs of the larger society. Diversity is not defined here as solely pertaining to race, ethnicity, or gender, although that weighs on decisions, but also on a range of interests and talents that students can develop and share with others during their college years. These are high-minded goals.
Fredrickson, a leading researcher of positive emotions at the University of North Carolina at Chapel Hill, presents scientific evidence to argue that love is not what we think it is. It is not a long-lasting, continually present emotion that sustains a marriage; it is not the yearning and passion that characterizes young love; and it is not the blood-tie of kinship.
Rather, it is what she calls a "micro-moment of positivity resonance." She means that love is a connection, characterized by a flood of positive emotions, which you share with another person—any other person—whom you happen to connect with in the course of your day. You can experience these micro-moments with your romantic partner, child, or close friend. But you can also fall in love, however momentarily, with less likely candidates, like a stranger on the street, a colleague at work, or an attendant at a grocery store. Louis Armstrong put it best in "It's a Wonderful World" when he sang, "I see friends shaking hands, sayin 'how do you do?' / They're really sayin', 'I love you.'"
The iconic conservative justice, who died Saturday at age 79, left an indelible stamp on the nation’s courts, its laws, and its understanding of itself.
Antonin Scalia, the judicial firebrand who stood as the intellectual leader of the U.S. Supreme Court’s conservative wing during his three-decade tenure as a justice, died Saturday at a ranch in western Texas. He was 79 years old.
“He was an extraordinary individual and jurist, admired and treasured by his colleagues. His passing is a great loss to the Court and the country he so loyally served,” Chief Justice John Roberts said in a statement on behalf of the Court.
President Obama, who will have the opportunity to nominate Scalia’s successor, offered his sympathies to the justice’s family on Saturday night. “He will no doubt be remembered as one of the most consequential judges to serve on the Supreme Court,” he said.
Science says lasting relationships come down to—you guessed it—kindness and generosity.
Every day in June, the most popular wedding month of the year, about 13,000 American couples will say “I do,” committing to a lifelong relationship that will be full of friendship, joy, and love that will carry them forward to their final days on this earth.
Except, of course, it doesn’t work out that way for most people. The majority of marriages fail, either ending in divorce and separation or devolving into bitterness and dysfunction. Of all the people who get married, only three in ten remain in healthy, happy marriages, as psychologist Ty Tashiro points out in his book The Science of Happily Ever After, which was published earlier this year.
Social scientists first started studying marriages by observing them in action in the 1970s in response to a crisis: Married couples were divorcing at unprecedented rates. Worried about the impact these divorces would have on the children of the broken marriages, psychologists decided to cast their scientific net on couples, bringing them into the lab to observe them and determine what the ingredients of a healthy, lasting relationship were. Was each unhappy family unhappy in its own way, as Tolstoy claimed, or did the miserable marriages all share something toxic in common?
The GOP presidential candidate—and at least two of his rivals—are acting as if the meaning of the Constitution changes depending on the timing of the next election.
Antonin Scalia is dead. Is it legitimate for the Republican-controlled Senate to refrain from confirming a replacement for the late Supreme Court justice until a new president is elected, as Ted Cruz, Marco Rubio, Ben Carson and others on the right have urged? Or does the Senate have an obligation to approve a qualified nominee put forth by President Obama, as many on the left argued as soon as news of the death broke?
The debate on Twitter was instantaneous. “The Democrat-controlled Senate confirmed Ronald Reagan's nominee to the Court, Anthony Kennedy, in his last year in office: 1988,” the liberal journalist Glenn Greenwald observed. Jim Antle, a paleoconservative, retorted with a Robert Bork reference, writing, “And it wouldn't quite have been in his final year if first choice had been confirmed in 1987.”
The number of American teens who excel at advanced math has surged. Why?
On a sultry evening last July, a tall, soft-spoken 17-year-old named David Stoner and nearly 600 other math whizzes from all over the world sat huddled in small groups around wicker bistro tables, talking in low voices and obsessively refreshing the browsers on their laptops. The air in the cavernous lobby of the Lotus Hotel Pang Suan Kaew in Chiang Mai, Thailand, was humid, recalls Stoner, whose light South Carolina accent warms his carefully chosen words. The tension in the room made it seem especially heavy, like the atmosphere at a high-stakes poker tournament.
Stoner and five teammates were representing the United States in the 56th International Mathematical Olympiad. They figured they’d done pretty well over the two days of competition. God knows, they’d trained hard. Stoner, like his teammates, had endured a grueling regime for more than a year—practicing tricky problems over breakfast before school and taking on more problems late into the evening after he completed the homework for his college-level math classes. Sometimes, he sketched out proofs on the large dry-erase board his dad had installed in his bedroom. Most nights, he put himself to sleep reading books like New Problems in Euclidean Geometry and An Introduction to Diophantine Equations.