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."
Years of misleading coverage left viewers so misinformed that many were shocked when confronted with the actual costs of repeal.
As the Republican Party struggled and then failed to repeal and replace Obamacare, pulling a wildly unpopular bill from the House without even taking a vote, a flurry of insightful articles helped the public understand what exactly just happened. Robert Draper explained the roles that Stephen Bannon, Paul Ryan, and others played in deciding what agenda items President Trump would pursue in what order. Politicoreported on how and why the House Freedom Caucus insisted that the health care bill repeal even relatively popular parts of Obamacare. Lest anyone pin blame for the GOP’s failure on that faction, Reihan Salam argued persuasively that responsibility rests with poor leadership by House Speaker Paul Ryan and a GOP coalition with “policy goals that simply can’t be achieved.”
In the final days of the Obama administration, scholars and journalists took stock of all that he had done to combat the dangerous rise of climate change. Barack Obama, they pronounced, had built up a surprisingly vast array of climate-concerned rules and guidelines across the government. He had turned the many policy-making tools of the many federal agencies toward preparing for this one imminent disaster.
Well, that was then.
On Tuesday, President Donald Trump will sign an executive order that will demolish his predecessor’s attempts to slow the pace of climate change. It is an omnibus directive that strikes across the federal government, reversing major rules that aim to restrict greenhouse-gas emissions while simultaneously instructing departments to ignore or downplay the risks of climate change in their decision-making.
Democrats want the chair of the committee looking into collusion between the Trump administration and Russia to recuse himself, and hearings have ground to a halt for the moment.
Embattled House Intelligence Committee chairman Devin Nunes is now facing Democratic calls for his recusal from an investigation into the Trump administration’s ties to Russia, as the inquiry grinds to what is at least a temporary halt.
The California Republican has been on the hot seat since announcing last week that he had vague but significant information about “incidental collection” of information about Trump transition team members by U.S. intelligence agencies. “Incidental collection” is when the communications of someone who is not the target of surveillance are picked up because they are corresponding with a target.
The Sony World Photography Awards has announced the winners of its Open categories and National categories for 2017.
The Sony World Photography Awards, an annual competition hosted by the World Photography Organisation, has announced the winners of its Open categories and National categories for 2017. This year's contest attracted 227,596 entries from 183 countries. The organizers have again been kind enough to share some of the winners and runners-up with us, gathered below. All captions below come from the photographers.
The program is based on the idea that habit-forming behaviors start in childhood.
At a Berlin day-care center, the children packed away all the toys: the cars, the tiny plastic animals, the blocks and Legos, even the board games and most of the art materials. They then stood in the empty classroom and looked at their two instructors.
“What should I do now?” my son, then 5, asked.
He did not get an answer to this question for a long time. His day-care center, or kita, was starting a toy-free kindergarten project. For several weeks, the toys would disappear, and the teachers wouldn’t tell the children what to play. While this practice may seem harsh, the project has an important pedagogic goal: to improve the children’s life skills to strengthen them against addictive behaviors in the future.
President Trump may feel liberated to pursue tax reform after the failure on health care. But the GOP’s to-do list in Congress only gets harder from here.
“In a way I’m glad I got it out of the way,” President Trump told the Washington Post last week in the moments after he and Republican leaders in Congress pulled the plug on their first major legislative priority, repealing and replacing the Affordable Care Act.
Health care was hard. Really hard. “Nobody knew that health care could be so complicated,” the president had said in a now-infamous quote. The health-care legislation was pulled without a vote last week after House Speaker Paul Ryan told the president there were not enough votes from Republicans to pass it.
The implication of Trump’s musings about the difficulty of passing complicated health-care legislation is that he believes the rest of his agenda will be much easier. Tax cuts? Everybody like tax cuts. The legendary border wall. More defense spending. A big, bipartisan infrastructure bill.
The comedian’s two Netflix specials are loaded with brilliant storytelling, but suffer when they lose hold of his unique point of view.
Almost exactly halfway through Deep in the Heart of Texas, the second of his two comedy specials released on Netflix last week, Dave Chappelle does something unusual: He sits down. The live-wire comic perches on a stool in the center of the stage, plops his feet onto a speaker, and asks the crowd if anyone has a cigarette. He delivers the rest of the show like that, occasionally springing to his feet to drive home a punchline, then resting back on his stool to chat with his rapt audience. It gives the show a spontaneous, conversational feel, as if he’s telling stories the instant he thinks of them.
Of course, every move in a stand-up show is a calculated one, and Chappelle is a veteran of the form, using a looser approach to sell a shaggier, more anecdotal form of his comedy. It makes for an interesting contrast to his other Netflix special, The Age of Spin, a more composed, finely tuned set with an overarching structure (based around four brief encounters with O.J. Simpson over the course of his career). But though they’re wildly different shows, the strengths and weaknesses of Chappelle’s comedy comeback are consistent in each.
The College Board earns over half of all its revenues from the courses—and, in an uncertain environment, students keep being suckered.
Fraudulent schemes come in all shapes and sizes. To work, they typically wear a patina of respectability. That's the case with Advanced Placement courses, one of the great frauds currently perpetrated on American high-school students.
That's a pretty strong claim, right? You bet. But why not be straightforward when discussing a scam the scale and audacity of which would raise Bernie Madoff's eyebrows?
The miscellany of AP courses offered in U.S. high schools under the imprimatur of the College Board probably started with good intentions. The idea, going back to the 1950s, was to offer college-level courses and exams to high-school students. The courses allegedly provide students the kind of rigorous academic experience they will encounter in college as well as an opportunity to earn college credit for the work.
On Wednesday, Britain’s exit from the EU becomes very real. That doesn’t mean it’s going to go according to plan.
At 12:30 p.m. on Wednesday afternoon, Sir Tim Barrow, the U.K.’s permanent representative to the EU, will hand-deliver a letter from British Prime Minister Theresa May to the office of European Council President Donald Tusk in Brussels, officially notifying the European Union of the U.K.’s intention to leave the 60-year-old bloc. The delivery of that letter will trigger Article 50, the statute of the EU Lisbon Treaty governing the procedure for the withdrawal of a member state.
The highly anticipated—and, for many, much-dreaded—“Brexit day” has been the subject of endless agonizing and political maneuvering since long before last Monday, when May announced the specific date upon which she will begin the years-long process of removing the U.K. from the EU. Yet many analysts say Wednesday’s invocation of Article 50, the first time a member state has ever signaled its intention to leave the EU, will be uneventful.
The president says he’s already succeeded in bringing auto-sector jobs back. Has he?
On Tuesday, Ford Motor Company announced a $1.2 billion investment in three Michigan plants—a move that was preceded by a 3:30 a.m. tweet from President Trump touting the job gains that the company’s announcement would bring. But as much as Trump tries to link himself to increases in auto-industry investment, the narrative is a dubious one. Massive car companies take a long time to make large investments, and it’s market forces, not White House policy, that are mostly behind recent moves from Mexico to the U.S.
According to Ford’s announcement, the company is putting $850 million towards retooling its Michigan Assembly Plant in Wayne to produce the resurrected Bronco SUV and Ranger pickup. It also plans to use $150 million to increase production at an engine parts plant in Romeo and to put $200 million towards a new data-storage facility in Flat Rock.