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."
In the name of emotional well-being, college students are increasingly demanding protection from words and ideas they don’t like. Here’s why that’s disastrous for education—and mental health.
Something strange is happening at America’s colleges and universities. A movement is arising, undirected and driven largely by students, to scrub campuses clean of words, ideas, and subjects that might cause discomfort or give offense. Last December, Jeannie Suk wrote in an online article for The New Yorker about law students asking her fellow professors at Harvard not to teach rape law—or, in one case, even use the word violate (as in “that violates the law”) lest it cause students distress. In February, Laura Kipnis, a professor at Northwestern University, wrote an essay in The Chronicle of Higher Education describing a new campus politics of sexual paranoia—and was then subjected to a long investigation after students who were offended by the article and by a tweet she’d sent filed Title IX complaints against her. In June, a professor protecting himself with a pseudonym wrote an essay for Vox describing how gingerly he now has to teach. “I’m a Liberal Professor, and My Liberal Students Terrify Me,” the headline said. A number of popular comedians, including Chris Rock, have stopped performing on college campuses (see Caitlin Flanagan’s article in this month’s issue). Jerry Seinfeld and Bill Maher have publicly condemned the oversensitivity of college students, saying too many of them can’t take a joke.
Heather Armstrong’s Dooce once drew millions of readers. Her blog’s semi-retirement speaks to the challenges of earning money as an individual blogger today.
The success story of Dooce.com was once blogger lore, told and re-told in playgroups and Meetups—anywhere hyper-verbal people with Wordpress accounts gathered. “It happened for that Dooce lady,” they would say. “It could happen for your blog, too.”
Dooce has its origin in the late 1990s, when a young lapsed Mormon named Heather Armstrong taught herself HTML code and moved to Los Angeles. She got a job in web design and began blogging about her life on her personal site, Dooce.com.
The site’s name evolved out of her friends’ AOL Instant-Messenger slang for dude, or its more incredulous cousin, "doooood!” About a year later, Armstrong was fired for writing about her co-workers on the site—an experience that, for a good portion of the ‘aughts, came known as “getting dooced.” She eloped with her now ex-husband, Jon, moved to Salt Lake City, and eventually started blogging full time again.
When Kenneth Jarecke photographed an Iraqi man burned alive, he thought it would change the way Americans saw the Gulf War. But the media wouldn’t run the picture.
The Iraqi soldier died attempting to pull himself up over the dashboard of his truck. The flames engulfed his vehicle and incinerated his body, turning him to dusty ash and blackened bone. In a photograph taken soon afterward, the soldier’s hand reaches out of the shattered windshield, which frames his face and chest. The colors and textures of his hand and shoulders look like those of the scorched and rusted metal around him. Fire has destroyed most of his features, leaving behind a skeletal face, fixed in a final rictus. He stares without eyes.
On February 28, 1991, Kenneth Jarecke stood in front of the charred man, parked amid the carbonized bodies of his fellow soldiers, and photographed him. At one point, before he died this dramatic mid-retreat death, the soldier had had a name. He’d fought in Saddam Hussein’s army and had a rank and an assignment and a unit. He might have been devoted to the dictator who sent him to occupy Kuwait and fight the Americans. Or he might have been an unlucky young man with no prospects, recruited off the streets of Baghdad.
It’s not just Trump: With Ben Carson and Carly Fiorina on the rise, Republicans are loving outsiders and shunning politicians.
For the first time in a long time, Donald Trump isn’t the most interesting story in the 2016 presidential race. That's partly because his dominance in the Republican polls, while still surprising, is no longer novel and increasingly well explored and explained, but it’s also partly because what’s going on with the rest of the GOP field is far more interesting.
The Islamic State is no mere collection of psychopaths. It is a religious group with carefully considered beliefs, among them that it is a key agent of the coming apocalypse. Here’s what that means for its strategy—and for how to stop it.
What is the Islamic State?
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.
ISIS did not merely blast apart old stones—it attacked the very foundations of pluralistic society.
If the ruined ruins of Palmyra could speak, they would marvel at our shock. After all, they have been sacked before. In their mute and shattered eloquence, they spoke for centuries not only about the cultures that built them but also about the cultures that destroyed them—about the fragility of civilization itself, even when it is incarnated in stone. No designation of sanctity, by God or by UNESCO, suffices to protect the past. The past is helpless. Instead these ruins, all ruins, have had the effect of lifting the past out of history and into time. They carry the spectator away from facts and toward reveries.
In the 18th century, after the publication in London of The Ruins of Palmyra, a pioneering volume of etchings by Robert Wood, who had traveled to the Syrian desert with the rather colorful James Dawkins, a fellow antiquarian and politician, the desolation of Palmyra became a recurring symbol for ephemerality and the vanity of all human endeavors. “It is the natural and common fate of cities,” Wood dryly remarked in one of the essays in his book, “to have their memory longer preserved than their ruins.” Wood’s beautiful and meticulous prints served as inspirations for paintings, and it was in response to one of those paintings that Diderot wrote some famous pages in his great Salons of 1767: “The ideas ruins evoke in me are grand. Everything comes to nothing, everything perishes, everything passes, only the world remains, only time endures. ... Wherever I cast my glance, the objects surrounding me announce death and compel my resignation to what awaits me. What is my ephemeral existence in comparison with that of a rock being worn down, of a valley being formed, of a forest that’s dying, of these deteriorating masses suspended above my head? I see the marble of tombs crumble into powder and I don’t want to die!”
In continuing to tinker with the universe she built eight years after it ended, J.K. Rowling might be falling into the same trap as Star Wars’s George Lucas.
September 1st, 2015 marked a curious footnote in Harry Potter marginalia: According to the series’s elaborate timeline, rarely referenced in the books themselves, it was the day James S. Potter, Harry’s eldest son, started school at Hogwarts. It’s not an event directly written about in the books, nor one of particular importance, but their creator, J.K. Rowling, dutifully took to Twitter to announce what amounts to footnote details: that James was sorted into House Gryffindor, just like his father, to the disappointment of Teddy Lupin, Harry’s godson, apparently a Hufflepuff.
It’s not earth-shattering information that Harry’s kid would end up in the same house his father was in, and the Harry Potter series’s insistence on sorting all of its characters into four broad personality quadrants largely based on their family names has always struggled to stand up to scrutiny. Still, Rowling’s tweet prompted much garment-rending among the books’ devoted fans. Can a tweet really amount to a piece of canonical information for a book? There isn’t much harm in Rowling providing these little embellishments years after her books were published, but even idle tinkering can be a dangerous path to take, with the obvious example being the insistent tweaks wrought by George Lucas on his Star Wars series.
Demonizing processed food may be dooming many to obesity and disease. Could embracing the drive-thru make us all healthier?
Late last year, in a small health-food eatery called Cafe Sprouts in Oberlin, Ohio, I had what may well have been the most wholesome beverage of my life. The friendly server patiently guided me to an apple-blueberry-kale-carrot smoothie-juice combination, which she spent the next several minutes preparing, mostly by shepherding farm-fresh produce into machinery. The result was tasty, but at 300 calories (by my rough calculation) in a 16-ounce cup, it was more than my diet could regularly absorb without consequences, nor was I about to make a habit of $9 shakes, healthy or not.
Inspired by the experience nonetheless, I tried again two months later at L.A.’s Real Food Daily, a popular vegan restaurant near Hollywood. I was initially wary of a low-calorie juice made almost entirely from green vegetables, but the server assured me it was a popular treat. I like to brag that I can eat anything, and I scarf down all sorts of raw vegetables like candy, but I could stomach only about a third of this oddly foamy, bitter concoction. It smelled like lawn clippings and tasted like liquid celery. It goes for $7.95, and I waited 10 minutes for it.
Though it wasn’t pretty, Minaj was really teaching a lesson in civility.
Nicki Minaj didn’t, in the end, say much to Miley Cyrus at all. If you only read the comments that lit up the Internet at last night’s MTV Video Music Awards, you might think she was kidding, or got cut off, when she “called out” the former Disney star who was hosting: “And now, back to this bitch that had a lot to say about me the other day in the press. Miley, what’s good?”
To summarize: When Minaj’s “Anaconda” won the award for Best Hip-Hop Video, she took to the stage in a slow shuffle, shook her booty with presenter Rebel Wilson, and then gave an acceptance speech in which she switched vocal personas as amusingly as she does in her best raps—street-preacher-like when telling women “don’t you be out here depending on these little snotty-nosed boys”; sweetness and light when thanking her fans and pastor. Then a wave of nausea seemed to come over her, and she turned her gaze toward Cyrus. To me, the look on her face, not the words that she said, was the news of the night:
The past is beautiful until you’re reminded it’s ugly.
Taylor Swift’s music video for “Wildest Dreams” isn’t about the world as it exists; it’s about the world as seen through the filter of nostalgia and the magic of entertainment. In the song, Swift sings that she wants to live on in an ex’s memory as an idealized image of glamour—“standing in a nice dress, staring at the sunset.” In the video, her character, an actress, falls in love with her already-coupled costar, for whom she’ll live on as an idealized image of glamour—standing in a nice dress, staring at a giant fan that’s making the fabric swirl in the wind.
The setting for the most part is Africa, but, again, the video isn’t about Africa as it exists, but as it’s seen through the filter of nostalgia and the magic of entertainment—a very particular nostalgia and kind of entertainment. Though set in 1950, the video is in the literary and cinematic tradition of white savannah romances, the most important recent incarnation of which might be the 1985 Meryl Streep film Out of Africa, whose story begins in 1913. Its familiarity is part of its appeal, and also part of why it’s now drawing flack for being insensitive. As James Kassaga Arinaitwe and Viviane Rutabingwa write at NPR: