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."
The ways some “healthy voice hearers” cope might be able to help people with psychotic disorders.
Jessica Dorner was lying in bed at her cousin’s house when her grandmother, a “pushy lady” in an apron who had been dead for several years, appeared in front of her. “I know you can see me,” Jessica heard her say, “and you need to do something about it.”
It was a lonely time in Jessica’s life. She was living away from home for the first time, and she thinks her grandmother was drawn by some sense of that. She eventually told her parents what happened, and according to her they were concerned, but not overly panicked. “My parents are probably the least judgmental people I know,” she said.
As Jessica tells it, over the next two years, spirits visited her every now and again. Her brother-in-law’s deceased father began forming before her, ghostlike, just as her grandmother did. And while the experiences were intense and at times made her feel “crazy,” she said, they were infrequent, and insists that they were never a real source of suffering.
In Trinity v. Comer, there was no remaining dispute between the actual parties—and both the majority opinion and the leading dissent got the issue wrong.
Trinity Lutheran Church v. Comer, the church-state case decided by the Supreme Court Monday, is a truly hard case. I can think of good arguments for either side, and even better arguments why—since there was no remaining dispute between the actual parties—the court should have stayed out altogether.
The court waded in, alas. And the majority opinion, by Chief Justice John Roberts, and the dissent, by Justice Sonia Sotomayor, got the issue wrong.
In Trinity Lutheran, a church challenged the state of Missouri’s refusal to fund safety improvements at its daycare playground. In April 2017, however, the newly elected governor of Missouri ordered the state to grant the funding and not to enforce its no-churches funding rule. The church won what it wanted because the state decided to give it—this being, for any judges unclear on the concept, what is wistfully called “the political process” courts are supposed to support, not supplant.
Discussing politics in groups of similarly minded people can be enough to stoke polarization—a frightening prospect in an era of social media.
For Cass Sunstein, a challenge that social media poses to democracy was clarified by a social-science experiment that he conducted in two different communities in Colorado: left-leaning Boulder and right-leaning Colorado Springs. Residents in each place were gathered into small groups to discuss their views on controversial topics, like climate change and same-sex marriage. Afterward, they were asked to report on the opinions of their groups as well as their own views on the subjects.
In 2004, people in the U.K. consumed more alcohol than ever before. How did they get there?
I first met alcohol in the late 1980s. It was the morning after one of my parents’ parties. My sister and I, aged 9 or 10, were up alone. We trawled the lounge for abandoned cans. I remember being methodical: Pick one up, give it a shake to see if there’s anything inside, and if there is, drink! I can still taste the stale, warm metallic tang of Heineken (lager; 5 percent alcohol by volume) on my tongue. Just mind the ones with cigarette butts in them.
Other times we’d sneak a sip of Dad’s Rémy Martin VSOP (cognac; 40 percent) when he wasn’t looking, even though we didn’t like the taste. It came in a heavy glass bottle that he kept in the sideboard. He’d pour himself a glass at night, the ice cubes clinking as he walked to his small office to make phone calls. On special occasions—family birthdays, Christmas lunch—we even got to drink legitimately: usually half a glass of Asti Spumanti (sparkling wine; around 7.5 percent), served in the best glasses.
Though Trump is skeptical of globalization, more investors from overseas are building factories and creating jobs. Will they find the U.S. a hospitable place for business?
MORAINE, Ohio—For years, Donjian Xu and her husband operated a sleepy Chinese restaurant in this industrial suburb of Dayton, cooking up American-style Chinese food like sweet-and-sour chicken and beef with broccoli for customers who would stop in on their lunch break.
Then, three years ago, a new crowd started coming into Dragon China: Chinese natives who missed home and were craving something different than the hamburgers and pasta that everybody seemed to eat in Ohio. The Chinese, mostly businessmen, would come in and order things not on the menu—noodle soup with vegetables and fish balls, for example. Sometimes, Cao Dewang, a famous self-made billionaire from China, would come in and sit at the corner table with his deputies, and “that’s when we [would] need to make something really special,” Xu told me.
The Republican health-care plan is especially bad for the elderly—which means it’s especially bad for everyone.
Good morning, fellow mortals!
At this pivotal moment in American policymaking, I’m here to remind you of our individual and collective doom. Wellness, like youth, is temporary. In the end, you either get sick, then die—or you die before you can get sick in the first place. It bears repeating, apparently, at a time when the health-care debate in the United States has become so partisan as to imply the population of sick people and well people is just as cleanly divided as Americans are politically split. But this isn’t the case.
You can’t choose to be healthy or ill the way you can choose to be a Republican or a Democrat. You can’t choose for your babies not to be born with medical problems.
You can do everything right to stay in good health. You can be one of “those people who lead good lives,” as the Alabama Republican Representative Mo Brooks put it in a television interview, explaining why healthy people should get to pay less for insurance than sick people. And you’re still likely to find yourself facing unexpected medical costs at one point or another.
If the party cares about winning, it needs to learn how to appeal to the white working class.
The strategy was simple. A demographic wave—long-building, still-building—would carry the party to victory, and liberalism to generational advantage. The wave was inevitable, unstoppable. It would not crest for many years, and in the meantime, there would be losses—losses in the midterms and in special elections; in statehouses and in districts and counties and municipalities outside major cities. Losses in places and elections where the white vote was especially strong.
But the presidency could offset these losses. Every four years the wave would swell, receding again thereafter but coming back in the next presidential cycle, higher, higher. The strategy was simple. The presidency was everything.
A Stanford professor argues that a profit imperative is in tension with the needs of a democratic society.
What news do people see? What do they believe to be true about the world around them? What do they do with that information as citizens—as voters?
Facebook, Google, and other giant technology companies have significant control over the answers to those questions. It’s no exaggeration to say that their decisions shape how billions see the world and, in the long run, will contribute to, or detract from, the health of governing institutions around the world.
That’s a hefty responsibility, but one that many tech companies say they want to uphold. For example, in an open letterin February, Facebook’s founder and CEO Mark Zuckerberg wrote that the company’s next focus would be “developing the social infrastructure for community—for supporting us, for keeping us safe, for informing us, for civic engagement, and for inclusion of all.”
A new study found that people who identify as Slytherins may be measurably different from the Hufflepuffs of the world.
I’m not particularly proud of this fact, but here it is: Pottermore, the Harry Potter-themed website unveiled by J.K. Rowling in 2012, has peered deep into my soul, evaluated its findings, and pronounced me a Hufflepuff.
Fans of the series will know why this is upsetting. For all the non-Harry Potter buffs reading this, though, here are three quick points of explanation. One: At Hogwarts, the wizards’ academy that serves as the backdrop for most of the series, students are sorted into one of four houses, each with its own distinctive character. Two: On Pottermore, fans can take a personality quiz to do the same. Three: Hufflepuff’s defining trait is “nice.” Its mascot is a badger. Its members, if Hogwarts were an American high-school cafeteria, would be the ones in the corner, frantically combing the trash for their retainers.
Cecile Richards says the organization will not spin off its abortion services, even though Congress is threatening to cut off a portion of the group’s funding.
The United States Congress is trying hard to defund Planned Parenthood, once and for all. For a period of one year, the proposed American Health Care Act would prohibit federal funds from going to non-profit organizations that provide family-planning services, including abortions, and get more than $350 million in reimbursements under Medicaid, which provides health insurance to the poor, the elderly, children, pregnant women, and people with disabilities. When the Congressional Budget Office evaluated this clause of the bill, it “identified only one organization that would be affected: Planned Parenthood Federation of America and its affiliates and clinics.”
If this bill goes through, it would represent an existential threat for Planned Parenthood. The organization would be less able to serve poor women who are covered by state Medicaid programs, and it would likely have to close clinics or reduce its services because of the loss of funding. The main motivation behind this provision—and others like it that have come up at the state level—is opposition to abortion. This has lead some, including Ivanka Trump, to wonder why Planned Parenthood doesn’t just spin off its abortion services into a separate organization.