I, Doctor

There’s some debate about who invented glasses, but one thing is clear: Humanity has been trying to improve people’s vision for hundreds of years. These days, nearly 30 percent of Americans are nearsighted, and as Baby Boomers get older, it’s expected that more optometrists will be needed in order to deal with their eye problems, such as cataracts. As a result, the number optometrists is expected to grow 27 percent in the next 10 years.

Hilary Hawthorne has been an optometrist for over 20 years. In California, where Hawthorne practices, many people have difficulties accessing optometry services because they can’t physically get to the places where optometrists see their patients. In the last few years, optometrists in California have also been pushing to expand the care they can legally provide to include medical care for conditions related to eyes.

For The Atlantic’s series of interviews with American workers, I spoke with Hawthorne about why she chose optometry, how she serves her community, and why the job continues to fulfill her. The interview that follows has been lightly edited for length and clarity.

Bourree Lam: What do you do as a optometrist, and how did you get into it?

Hilary Hawthorne: I'm a native of California. I graduated from Pacific University College of Optometry in Oregon, and I wondered about where I would want to provide eye care. Would it be in my home state or perhaps traveling to a different state? After I completed my undergraduate degree, and graduated from a four-year optometry school, I applied for my license through the state of California.

I was interested in taking care of patients in the community that I was part of. From a very early stage [of my career], I was looking at demographics and communities. I landed at my current practice by working for a doctor nearby, and then moving over into a private practice.

On a day-to-day basis, I am taking care of patients. We're just not providers of eyeglasses or contact lenses; in California we prescribe medications that treat certain eye-health conditions. If there's an eye infection or an injury, we are doing minor surgical procedures, as well as prescribing medications to correct eye infections or eye inflammation.

Since I graduated in 1992, California has changed its laws and allowed optometrists to treat glaucoma. I've kept up with my licensure for the types of services that we're allowed to do in this state. You have to make a decision based on where you want to practice, how you want to practice, and what conditions you want to care for or treat.

Lam: Have you always wanted to be an optometrist?

Hawthorne: Yes. As an undergraduate, I was taking courses alongside other pre-med, pre-dental, pre-pharmacy students. You're taking the same courses, but then you have to determine where you would like to further your studies. Of the choices, I worked for a couple of providers who were pharmacists and looked at other health professions—and I just decided this was a good fit.

Basically, as an optometrist, you're seeing pretty healthy patients overall. Their concerns are conditions. There aren't as many emergencies in optometry, per se. It makes for a lifestyle where you're not working extended hours. It's a well-kept secret that we have a pretty steady schedule: Arriving at work usually the same time each day, and a typical day does not run into overtime.

Lam: Besides the regularity of the work schedule, what else drew you to optometry?

Hawthorne: The deciding factors came while I was working for a practitioner in an office observing the dynamics of what goes on on a day-to-day basis. You eventually ask yourself: Is this something I want to do for the rest of my life? Looking at the stress level, the administrative tasks, the staff requirements, and support systems that's involved, it was a good fit.

Lam: You mentioned that serving patients in your community was a deciding factor. What does that mean to you?

Hawthorne: It has to do with where health-care needs are: A lot of people graduate after spending a good period of time accumulating student loans, and you want to pay them off quickly by going into a practice that will be successful and thrive.

But you can't have every graduating student from all the health-profession schools all in the metropolitan areas working in the same four square-miles. California is a large state; it has rural environments. It has metropolitan areas that are densely populated, but there are underserved areas. It may be the lack of transportation. For areas of lower socioeconomic status, there's a need there. To provide expertise and skills for patients at this level, you're improving their quality of life. That was something that I wanted to do because patient care takes education, it takes patience, and you improve the outcome in the community. I think [what I do now] does more for our state than I could have done in a different profession.

Lam: Do you get the sense that your patients know that’s how you feel about your work?

Hawthorne: Actually, I do. I've been practicing for 23 years, and I've been in my own private practice for 19 years. My patients have reminded me of why I'm still here.

A lot of times, they say things like, “We're so glad you're still in the community. We're so glad that you're here to help us.” I think they recognize the fact that it takes commitment and dedicated staff that will remain in a community as it changes, and still be able to provide that care to a patient, their children, and their parents.

Lam: What are some challenges you face in your line of work?

Hawthorne: The insurance access to care is a big issue. Access to care is being solved in a very unusual way that I wouldn't have anticipated when I started practicing years ago. When we talk about the shortcomings of providing care to patients, we can talk about the demographics or transportation: Can they get to doctors' offices if they have to travel long distances or don't have time to take off work?

All of a sudden, we have technology now that's trying to provide an eye test online. We have a lot of misconceptions that that is a sufficient substitute, and it is not. An eye-health exam is comprehensive. It involves actual patient care that's face-to-face. The development of this quick and easy so-called substitute is frightening. The same thing as one who goes to the DMV and says, "I went to the DMV and they checked my eyes." No, they screened you to see if you were qualified to use a vehicle. They did not examine your eyes.

Lam: What's the danger in equating those two things?

Hawthorne: It is a problem because there are painless diseases that develop in an eye [that could eventually cause you to]  lose sight. We have a percentage of patients that have health conditions, such as diabetes and hypertension, which have secondary effects for the eye. The leading cause of blindness can be from diabetic retinopathy for certain individuals. Glaucoma is undetected by a screening.

If patients are continually receiving false reassurances, they can receive an eye-health assessment and be waved through as not having any vision difficulties. But there are things that go beyond that, and we are trained to have expertise in using the eyes together, teaming the eyes, and looking for conditions of farsightedness. Those are the things that we argue need to be evaluated for healthy individuals.

Lam: Is blindness the most extreme thing that you would say you're trying to prevent?

Hawthorne: That's our ultimate goal, is that we do not want to see patients under our care suffer. To allow a patient to use their eyes to the best of their ability helps improve the quality of their life. Unfortunately, it goes a lot of different directions, and I wouldn't say there's one specific worst-case scenario of a lot of things that we see, but that's why optometry has different branches. It makes me smile that there are so many ways that I can care for patients.

Lam: What motivates you to come to work everyday?

Hawthorne: Probably the day that I just finished.

Lam: It sounds like you really enjoy your work.

Hawthorne: Absolutely. [But] it does have its limitations. I do wish that the laws that govern how we practice state by state were broader; if we had the ability to care for patients without having to legislate everything that we provide. We're trained well above what the state allows, but the argument is that the access to care has been worked out. Every nurse practitioner, optometrist, or other sources of health care have always argued we could do more to help the problem so that we're not having a patient with pink-eye go to the emergency room and spend excess dollars on something that could be solved much more cost-effectively in a practitioner's office who's qualified.

Lam: How do you think that your work relates to your personal identity?

Hawthorne: I think when I first graduated, I still had all of the motivation and thrill of providing an eye exam that was thorough. It was done many times during a busy day. Now, I enjoy the fact that my identity with doing health care is that I've reached the level of expertise that I thought this profession would provide. In the beginning, I think I really thought of it as, “This has been really exciting. I've got a lot of this training under my belt, and I can't wait to use it.” Now it's the reverse. I've enjoyed the training and how it has built into a career that I thought it would become. I think that took 20 years to arrive at.

Lam: Why is that particular aspect meaningful to you?

Hawthorne: I think it doesn't happen for everyone [who works in health care], because you’re treating healthy patients and you're taking care of needs. You're able to have a complete experience for each person that you see. In other professions, I think that sometimes it's not as rewarding. This [profession] does not end—it renews, it continues to still provide that same expertise that works, and I like that about it.

The fact that I'm providing a patient with a medical device that they can utilize to improve what they do on a day-to-day basis—that's important. I built this practice based on providing that care for everyone that comes through the door; I want to make sure they receive it.

I think it took 20 years to realize that, you know what, it went really quickly.That motivates me every day to come to work to do it. I remember there was an article in U.S. News and World Report, and we’re number 11 for one of the best professions. I remember seeing that article, the little clip, and I went, "Huh, see, I'm not just looking at this from my own perspective.”

This interview is a part of a series about the lives and experiences of members of the American workforce, which includes conversations with a real estate agent, a surgeon, and a sexual assault nurse.

Bourree Lam is a former staff writer at The Atlantic. She was previously the editor of Freakonomics.com.

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