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."
After more than a year of rumors and speculation, Bruce Jenner publicly came out as transgender with four simple words: “I am a woman.”
“My brain is much more female than male,” he explained to Diane Sawyer, who conducted a primetime interview with Jenner on ABC Friday night. (Jenner indicated he prefers to be addressed with male pronouns at this time.) During the two-hour program, Jenner discussed his personal struggle with gender dysphoria and personal identity, how it shaped his past and current relationships and marriages, and how he finally told his family about his true gender identity.
The show went to impressive lengths to explain unfamiliar concepts of gender and sexuality to its audience, although it didn't always go smoothly. Sawyer’s questions occasionally came off as awkward and tone-deaf, mirroring a broader lack of understanding by many Americans about the difficulties that trans people face. But Sawyer’s empathy also shone when explaining concepts like gender identity and transitioning to her audience—a rare experience on primetime American television. It was a powerful signal of how much progress the LGBT movement has made over the past twenty years, even though the T in that acronym still lags behind the other three letters in both social acceptance and legal protections, and in how much progress remains to be made.
In her new book No One Understands You and What To Do About It, Heidi Grant Halvorson tells readers a story about her friend, Tim. When Tim started a new job as a manager, one of his top priorities was communicating to his team that he valued each member’s input. So at team meetings, as each member spoke up about whatever project they were working on, Tim made sure he put on his “active-listening face” to signal that he cared about what each person was saying.
But after meeting with him a few times, Tim’s team got a very different message from the one he intended to send. “After a few weeks of meetings,” Halvorson explains, “one team member finally summoned up the courage to ask him the question that had been on everyone’s mind.” That question was: “Tim, are you angry with us right now?” When Tim explained that he wasn’t at all angry—that he was just putting on his “active-listening face”—his colleague gently explained that his active-listening face looked a lot like his angry face.
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.
Today was the latest installment of the never-ending Clinton scandal saga, but it won’t be the last. Yet in some ways, the specifics are a distraction. The sale of access was designed into the post-2001 Clinton family finances from the start. Probably nobody will ever prove that this quid led to that quo … but there’s about a quarter-billion-dollar of quid heaped in plain sight and an equally impressive pile of quo, and it’s all been visible for years to anyone who cared to notice. As Jonathan Chait, who is no right-wing noise-machine operator, complained: “The Clintons have been disorganized and greedy.”
“All of this amounts to diddly-squat,” pronounced long-time Clinton associate James Carville when news broke that Hillary Clinton had erased huge numbers of emails. That may not be true: If any of the conduct in question proves illegal, destroying relevant records may also have run afoul of the law.
The editors of Smithsonian magazine have announced the winners of their 12th annual photo contest, selected from more than 26,500 entries. The winning photographs from from the competition's six categories are published below: The Natural World, Travel, People, Americana, Altered Images and Mobile. Also, a few finalists have been included as well. Captions were written by the photographers. Be sure to visit the contest page at Smithsonian.com to see all the winners and finalists.
Mary Hamm was in pain, though it was hard to tell. She bustled around the Starbucks, pouring drinks, restocking pastries, and greeting customers with an unshakable gaze perfected during 25 years of working in hospitality. Her smile said, How can I help you? Her eyes said, I know you’re going to order a caramel Frappuccino, so let’s do this.
Occupying prime space in a Fredericksburg, Virginia, strip mall, beside a Dixie Bones BBQ Post, this Starbucks pulls in about $40,000 a week. Hamm, 49, had been managing Starbucks stores for 12 years. The problem was her feet. After two decades in the food-service business, they had started to wear out. She had two metal plates in the right one, installed over the course of five surgeries. Now her left foot needed surgery too. She doesn’t like to complain, but when I asked her how often she was in pain, she smiled and said quietly, “All the time.”
Leon Trotsky is not often invoked as a management guru, but a line frequently attributed to him would surely resonate with many business leaders today. “You may not be interested in war,” the Bolshevik revolutionary is said to have warned, “but war is interested in you.” War, or at least geopolitics, is figuring more and more prominently in the thinking and fortunes of large businesses.
Of course, multinational companies such as Shell and GE have long cultivated an expertise in geopolitics. But the intensity of concern over global instability is much higher now than in any recent period. In 2013, the private-equity colossus KKR named the retired general and CIA director David Petraeus as the chairman of its global institute, which informs the firm’s investment decisions. Earlier this year, Sir John Sawers, the former head of MI6, Britain’s CIA, became the chairman of Macro Advisory Partners, a firm that advises businesses and governments on geopolitics. Both appointments are high-profile examples of a much wider trend: an increasing number of corporations are hiring political scientists, starting their board meetings with geopolitical briefings, and seeking the advice of former diplomats, spymasters, and military leaders.“The last three years have definitely been a wake-up call for business on geopolitics,” Dominic Barton, the managing director of McKinsey, told me. “I’ve not seen anything like it. Since the Second World War, I don’t think you’ve seen such volatility.” Most businesses haven’t pulled back meaningfully from globalized operation, Barton said. “But they are thinking, Gosh, what’s next?”
When healthcare is at its best, hospitals are four-star hotels, and nurses, personal butlers at the ready—at least, that’s how many hospitals seem to interpret a government mandate.
When Department of Health and Human Services administrators decided to base 30 percent of hospitals’ Medicare reimbursement on patient satisfaction survey scores, they likely figured that transparency and accountability would improve healthcare. The Centers for Medicare and Medicaid Services (CMS) officials wrote, rather reasonably, “Delivery of high-quality, patient-centered care requires us to carefully consider the patient’s experience in the hospital inpatient setting.” They probably had no idea that their methods could end up indirectly harming patients.
New Zealand's largest newspaper is deeply conflicted. With the World Cup underway in Brazil, should The New Zealand Herald refer to the "global round-ball game" as "soccer" or "football"? The question has been put to readers, and the readers have spoken. It's "football"—by a wide margin.
We in the U.S., of course, would disagree. And now we have a clearer understanding of why. In May, Stefan Szymanski, a sports economist at the University of Michigan, published a paper debunking the notion that "soccer" is a semantically bizarre American invention. In fact, it's a British import. And the Brits used it often—until, that is, it became too much of an Americanism for British English to bear.
The story begins, like many good stories do, in a pub. As early as the Middle Ages, Szymanski explains, the rough outlines of soccer—a game, a ball, feet—appear to have been present in England. But it wasn't until the sport became popular among aristocratic boys at schools like Eton and Rugby in the nineteenth century that these young men tried to standardize play. On a Monday evening in October 1863, the leaders of a dozen clubs met at the Freemasons' Tavern in London to establish "a definite code of rules for the regulation of the game.” They did just that, forming the Football Association. The most divisive issue was whether to permit "hacking," or kicking an opponent in the leg (the answer, ultimately, was 'no').
This month, many of the nation's best and brightest high school seniors will receive thick envelopes in the mail announcing their admission to the college of their dreams. According to a 2011 survey, about 60 percent of them will go to their first-choice schools. For many of them, going away to college will be like crossing the Rubicon. They will leave their families -- their homes -- and probably not return for many years, if at all.
That was journalist Rod Dreher's path. Dreher grew up in the small southern community of Starhill, Louisiana, 35 miles northwest of Baton Rouge. His family goes back five generations there. His father was a part-time farmer and sanitarian; his mother drove a school bus. His younger sister Ruthie loved hunting and fishing, even as a little girl.