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."
It’s a paradox: Shouldn’t the most accomplished be well equipped to make choices that maximize life satisfaction?
There are three things, once one’s basic needs are satisfied, that academic literature points to as the ingredients for happiness: having meaningful social relationships, being good at whatever it is one spends one’s days doing, and having the freedom to make life decisions independently.
But research into happiness has also yielded something a little less obvious: Being better educated, richer, or more accomplished doesn’t do much to predict whether someone will be happy. In fact, it might mean someone is less likely to be satisfied with life.
That second finding is the puzzle that Raj Raghunathan, a professor of marketing at The University of Texas at Austin’s McCombs School of Business, tries to make sense of in his recent book, If You’re So Smart, Why Aren’t You Happy?Raghunathan’s writing does fall under the category of self-help (with all of the pep talks and progress worksheets that that entails), but his commitment to scientific research serves as ballast for the genre’s more glib tendencies.
...isn't something that can be done on campus. It's an internship.
When I was 17, if you asked me how I planned on getting a job in the future, I think I would have said: Get into the right college. When I was 18, if you asked me the same question, I would have said: Get into the right classes. When I was 19: Get good grades.
But when employers recently named the most important elements in hiring a recent graduate, college reputation, GPA, and courses finished at the bottom of the list. At the top, according to the Chronicle of Higher Education, were experiences outside of academics: Internships, jobs, volunteering, and extracurriculars.
What Employers Want
"When employers do hire from college, the evidence suggests that academic skills are not their primary concern," says Peter Cappelli, a Wharton professor and the author of a new paper on job skills. "Work experience is the crucial attribute that employers want even for students who have yet to work full-time."
Two scholars discuss the ups and downs of life as a right-leaning professor.
“I don’t think I can say it too strongly, but literally it just changed my life,” said a scholar, about reading the work of Ayn Rand. “It was like this awakening for me.”
Different versions of this comment appear throughout Jon A. Shields and Joshua M. Dunn Sr.’s book on conservative professors, Passing on the Right, usually about people like Milton Friedman and John Stuart Mill and Friedrich Hayek. The scholars they interviewed speak in a dreamy way about these nerdy celebrities, perhaps imagining an alternate academic universe—one where social scientists can be freely conservative.
The assumption that most college campuses lean left is so widespread in American culture that it has almost become a caricature: intellectuals in thick-rimmed glasses preaching Marxism on idyllic grassy quads; students protesting minor infractions against political correctness; raging professors trying to prove that God is, in fact, dead. Studies about professors’ political beliefs and voting behavior suggest this assumption is at least somewhat correct. But Shields and Dunn set out to investigate a more nuanced question: For the minority of professors who are cultural and political conservatives, what’s life actually like?
Nearly half of Americans would have trouble finding $400 to pay for an emergency. I’m one of them.
Since 2013,the Federal Reserve Board has conducted a survey to “monitor the financial and economic status of American consumers.” Most of the data in the latest survey, frankly, are less than earth-shattering: 49 percent of part-time workers would prefer to work more hours at their current wage; 29 percent of Americans expect to earn a higher income in the coming year; 43 percent of homeowners who have owned their home for at least a year believe its value has increased. But the answer to one question was astonishing. The Fed asked respondents how they would pay for a $400 emergency. The answer: 47 percent of respondents said that either they would cover the expense by borrowing or selling something, or they would not be able to come up with the $400 at all. Four hundred dollars! Who knew?
A professor of cognitive science argues that the world is nothing like the one we experience through our senses.
As we go about our daily lives, we tend to assume that our perceptions—sights, sounds, textures, tastes—are an accurate portrayal of the real world. Sure, when we stop and think about it—or when we find ourselves fooled by a perceptual illusion—we realize with a jolt that what we perceive is never the world directly, but rather our brain’s best guess at what that world is like, a kind of internal simulation of an external reality. Still, we bank on the fact that our simulation is a reasonably decent one. If it wasn’t, wouldn’t evolution have weeded us out by now? The true reality might be forever beyond our reach, but surely our senses give us at least an inkling of what it’s really like.
The president’s unique approach to the White House Correspondents’ Dinner will surely be missed.
No U.S. President has been a better comedian than Barack Obama. It’s really that simple.
Now that doesn’t mean that some modern-day presidents couldn’t tell a joke. John F. Kennedy, Ronald Reagan, and Bill Clinton excelled at it. But Obama has transformed the way presidents use comedy—not just engaging in self-deprecation or playfully teasing his rivals, but turning his barbed wit on his opponents.
He puts that approach on display every year at the White House Correspondents’ Dinner. This annual tradition, which began in 1921 when 50 journalists (all men) gathered in Washington D.C., has become a showcase for each president’s comedy chops. Some presidents have been bad, some have been good. Obama has been the best. He’s truly the killer comedian in chief.
“A typical person is more than five times as likely to die in an extinction event as in a car crash,” says a new report.
Nuclear war. Climate change. Pandemics that kill tens of millions.
These are the most viable threats to globally organized civilization. They’re the stuff of nightmares and blockbusters—but unlike sea monsters or zombie viruses, they’re real, part of the calculus that political leaders consider everyday. And according to a new report from the U.K.-based Global Challenges Foundation, they’re much more likely than we might think.
In its annual report on “global catastrophic risk,” the nonprofit debuted a startling statistic: Across the span of their lives, the average American is more than five times likelier to die during a human-extinction event than in a car crash.
Partly that’s because the average person will probably not die in an automobile accident. Every year, one in 9,395 people die in a crash; that translates to about a 0.01 percent chance per year. But that chance compounds over the course of a lifetime. At life-long scales, one in 120 Americans die in an accident.
After the successful Allied invasions of western France, Germany gathered reserve forces and launched a massive counter-offensive in the Ardennes, which collapsed by January. At the same time, Soviet forces were closing in from the east, invading Poland and East Prussia. By March, Western Allied forces were crossing the Rhine River, capturing hundreds of thousands of troops from Germany's Army Group B. The Red Army had meanwhile entered Austria, and both fronts quickly approached Berlin. Strategic bombing campaigns by Allied aircraft were pounding German territory, sometimes destroying entire cities in a night. In the first several months of 1945, Germany put up a fierce defense, but rapidly lost territory, ran out of supplies, and exhausted its options. In April, Allied forces pushed through the German defensive line in Italy. East met West on the River Elbe on April 25, 1945, when Soviet and American troops met near Torgau, Germany. Then came the end of the Third Reich, as the Soviets took Berlin, Adolf Hitler committed suicide on April 30, and Germany surrendered unconditionally on all fronts on May 8 (May 7 on the Western Front). Hitler's planned "Thousand-Year Reich" lasted only 12 incredibly destructive years. (This entry is Part 17 of a weekly
The U.S. president talks through his hardest decisions about America’s role in the world.
Friday, August 30, 2013, the day the feckless Barack Obama brought to a premature end America’s reign as the world’s sole indispensable superpower—or, alternatively, the day the sagacious Barack Obama peered into the Middle Eastern abyss and stepped back from the consuming void—began with a thundering speech given on Obama’s behalf by his secretary of state, John Kerry, in Washington, D.C. The subject of Kerry’s uncharacteristically Churchillian remarks, delivered in the Treaty Room at the State Department, was the gassing of civilians by the president of Syria, Bashar al-Assad.
Why thyroid diseases are so common—and still so mysterious
When I first suspected I was suffering from hypothyroidism, I did what any anxious, Internet-connected person would do and Googled "dysfunctional thyroid symptoms," and, in another tab, "hypothyroid thinning hair??" for good measure.
What came up sounded like someone describing me for an intimately detailed police sketch:
heightened sensitivity to cold
unexplained weight gain
a pale, puffy face ("Finally, a medical explanation for this," I thought.)
This, combined with the fact that a close family member had recently been diagnosed with a thyroid disorder, sent me scurrying to the nearest endocrinologist's office. They took a blood test, and two weeks later the results came back. Sure enough, the doctor said solemnly, I had hypothyroidism, which meant my thyroid was under-active. She would be starting me on thyroid medication. She couldn't know for sure, but I might have to take drugs for the rest of my life.