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."
A conversation with Nikole Hannah-Jones about race, education, and hypocrisy.
Public schools in gentrifying neighborhoods seem on the cusp of becoming truly diverse, as historically underserved neighborhoods fill up with younger, whiter families. But the schools remain stubbornly segregated. Nikole Hannah-Jones has chronicled this phenomenon around the country, and seen it firsthand in her neighborhood in Brooklyn.
“White communities want neighborhood schools if their neighborhood school is white,” she says. “If their neighborhood school is black, they want choice.” Charter schools and magnet schools spring up in place of neighborhood schools, where white students can be in the majority.
“We have a system where white people control the outcomes, and the outcome that most white Americans want is segregation,” she says.
The first episode of the Streaming Wars is over. The rebels won. Now the empire strikes back.
Disney announced on Thursday that it would acquire most of the entertainment assets of 21st Century Fox for about $60 billion in stock and debt, in what would be the largest-ever merger of two showbiz companies. Already the most storied entertainment empire in the U.S., Disney would become a global colossus through this deal, gaining large stakes in the biggest entertainment companies in both Europe and India. The deal will almost certainly receive regulatory scrutiny, as the Justice Department has been lately dubious of mega media mergers.
The yuletide haul includes some of the most famous properties in television and film. In the transfer of power, Disney would receive the 20th Century Fox film studio, including the independent film maestros at Fox Searchlight (Best Picture Oscar–winners include: Slumdog Millionaire, 12 Years a Slave, and Birdman), the X-Men franchise, Fox’s television production company (worldwide hits include: The Simpsons, Modern Family, and Homeland), the FX and National Geographic cable channels, and regional sports networks, including the YES Network that broadcasts New York Yankees games. Disney also acquires a majority stake in the TV product Hulu, which it may use to kickstart its entry into the streaming wars.
With Hindu nationalism ascendant, what does the future hold for India’s first family and its pluralist legacy?
In 1994, Sonia Gandhi published a book of photographs from her private life with her late husband, Rajiv Gandhi. It included a dozen pictures from their trips to Italy, where she had grown up in the suburbs of Turin. Here she was in a speedboat in 1980, wearing crimson-framed sunglasses and a matched paisley shawl. Here was their son Rahul, just seven or eight years old, on a beach pushing goggles off his face into his hair.
What made the book, titled Rajiv’s World, so unusual then was the photographer: Rajiv Gandhi, the former prime minister of India killed in a suicide bombing. What makes the book unusual today is how much it shares of the interior life of Sonia herself—before she transcended her origins to become India’s most powerful politician.
The first authorized biography of a controversial Italian reporter sheds a new light on her legacy.
The Italian journalist Oriana Fallaci was born in 1929, before the outbreak of World War II, and died in 2006, after 9/11. These two horrifying events shaped her writing and worldview. Traveling the world, she covered some of its worst conflicts as a war reporter, with a tone fans would call incisive and critics would call caustic. In the process, she developed a deep fear of Islam’s influence in Europe.
She is most remembered—and often reviled—for the views informed by this fear. Fallaci believed that the Western world was in danger of being engulfed by radical Islam and, toward the end of her career, she wrote three books advancing this argument. She claimed that Muslims were colonizing Europe through immigration and high fertility, and that the passivity of the European left to the dangers she saw would soon turn Europe into a “colony of Islam,” a place she called “Eurabia.”
Don't make a scene. Look the other way. Social discomfort has long been used to maintain the status quo.
“Young women say yes to sex they don’t actually want to have all of the time. Why? Because we condition young women to feel guilty if they change their mind.”
That was the writer Ella Dawson, in her essay reacting to “Cat Person,” the New Yorker short story that went viral, and indeed that is still going viral, this week. Kristen Roupenian’s work of fiction resonated among denizens of the nonfictional world in part because of its sex scene: one that explores, in rich and wincing detail, the complications of consent. Margot, a 20-year-old college student, goes on a date with Robert, a man several years her senior; alternately enchanted by him and repulsed by him, hopeful about him and disappointed, she ultimately sleeps with him. Not because she fully wants to, in the end, but because, in the dull heat of the moment, acquiescing is easier—less dramatic, less disruptive, less awkward—than saying no.
Democratic men are 31 points more likely to say that the “country has not gone far enough on women’s rights” than Republican women.
Amidst the exhilaration of Roy Moore’s defeat, and the broader cultural revolution sparked by women’s willingness to expose the sexual misdeeds of powerful men, it’s worth remembering this: Ninety percent of Republican women in Alabama, according to exit polls, cast their ballots for a man credibly accused of pedophilia. That’s a mere two points less than Republican men. By contrast, Democratic men voted for Moore’s opponent, Doug Jones, at the same rate as Democratic women: 98 percent. In early December, The Washington Postand the Schar School at George Mason University asked Alabamians whether they believed the allegations against Moore.
At my request, researchers from the Schar School broke down the answers by party and gender. The results: Party mattered far more. Republican women in Alabama were only four points more likely than Republican men to believe Moore’s accusers. In fact, Republican women were 40 points less likely to believe Moore’s accusers than were Democratic men. All of which points to a truth insufficiently appreciated in this moment of sexual and political upheaval: It’s not gender that increasingly divides the two parties. It is feminism.
The internet is as much the enemy as it is the hero of contemporary life.
Ajit Pai, the chairman of the Federal Communications Commission, opens a bag of Cheetos with his teeth, dumps them onto a hipster food-court lunch bowl, and slathers it in Sriracha sauce. He snaps a pic for social media.
It’s a scene from a video, “Seven Things You Can Still Do on the Internet After Net Neutrality,” shot by the conservative outlet The Daily Caller and published Wednesday, the day before the Federal Communications Commission voted to gut rules to treat internet traffic equally. Besides “’gramming your food,” Pai also assures The Daily Caller’s readers they will still be able to take selfies, binge watch Game of Thrones, cosplay as a Jedi, and do the Harlem shake.
Net-neutrality proponents have lambasted the video, and with good reason. A federal appointee charged for stewardship of public communications infrastructure comes off as insolent.
Russia's strongman president has many Americans convinced of his manipulative genius. He's really just a gambler who won big.
I. The Hack
The large, sunny room at Volgograd State University smelled like its contents: 45 college students, all but one of them male, hunched over keyboards, whispering and quietly clacking away among empty cans of Juicy energy drink. “It looks like they’re just picking at their screens, but the battle is intense,” Victor Minin said as we sat watching them.
Clustered in seven teams from universities across Russia, they were almost halfway into an eight-hour hacking competition, trying to solve forensic problems that ranged from identifying a computer virus’s origins to finding secret messages embedded in images. Minin was there to oversee the competition, called Capture the Flag, which had been put on by his organization, the Association of Chief Information Security Officers, or ARSIB in Russian. ARSIB runs Capture the Flag competitions at schools all over Russia, as well as massive, multiday hackathons in which one team defends its server as another team attacks it. In April, hundreds of young hackers participated in one of them.
Her perspective has a lot of intuitive appeal in an era where millions of women have children outside of marriage, serve as breadwinner moms to their families, or are raising children on their own. Dads certainly seem dispensable in today's world.
What this view overlooks, however, is a growing body of research suggesting that men bring much more to the parenting enterprise than money, especially today, when many fathers are highly involved in the warp and woof of childrearing. As Yale psychiatrist Kyle Pruett put it in Salon: "fathers don't mother."
Content moderators review the the dark side of the internet. They don’t escape unscathed.
Lurking inside every website or app that relies on “user-generated content”—so, Facebook, YouTube, Twitter, Instagram, Pinterest, among others—there is a hidden kind of labor, without which these sites would not be viable businesses. Content moderation was once generally a volunteer activity, something people took on because they were embedded in communities that they wanted to maintain.
But as social media grew up, so did moderation. It became what the University of California, Los Angeles, scholar Sarah T. Roberts calls, “commercial content moderation,” a form of paid labor that requires people to review posts—pictures, videos, text—very quickly and at scale.
Roberts has been studying the labor of content moderation for most of a decade, ever since she saw a newspaper clipping about a small company in the Midwest that took on outsourced moderation work.