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 president’s latest comments shouldn’t be surprising—but his deliberate inflammation of tense situations is no less stunning.
During last year’s presidential campaign, I conducted a running feature called the “Trump Time Capsule.” Its purpose was to chronicle the things Donald Trump said or did that were entirely outside the range of previous presidents or major-party nominees. This, in turn, was meant to lay down a record of what was known about this man, as the electorate decided whether to elevate him to presidential power.
By the time the campaign ended, the series had reached installment #152. Who Donald Trump was, and is, was absolutely clear by election day: ignorant, biased, narcissistic, dishonest. As Ta-Nehisi Coates argues in our current issue, everyone who voted for him did so with ample evidence about the kind of person they considered the “better” choice, or even as a minimally acceptable choice for president. Almost nothing Trump has done since taking office should come as a surprise.
At a game played in London on Sunday afternoon, many of their fellow Ravens and Jaguars took a knee.
Before the Lions met the Falcons in Detroit on Sunday, Rico LaVelle sang “The Star-Spangled Banner.” And then he took a knee.
They were replicating the gesture of Colin Kaepernick, the former 49ers quarterback who, starting in 2016, had been kneeling during the pre-game singing of the national anthem. “I am not going to stand up to show pride in a flag for a country that oppresses black people and people of color,” Kaepernick explained. “To me, this is bigger than football and it would be selfish on my part to look the other way. There are bodies in the street and people getting paid leave and getting away with murder.” Kaepernick’s 49ers teammates, Eric Reid and Eli Harold, took a knee. The Beaumont Bulls, a high school team, took a knee. Their collective protests, however, had been limited—deviations from the norm.
The foundation of Donald Trump’s presidency is the negation of Barack Obama’s legacy.
It is insufficient to statethe obvious of Donald Trump: that he is a white man who would not be president were it not for this fact. With one immediate exception, Trump’s predecessors made their way to high office through the passive power of whiteness—that bloody heirloom which cannot ensure mastery of all events but can conjure a tailwind for most of them. Land theft and human plunder cleared the grounds for Trump’s forefathers and barred others from it. Once upon the field, these men became soldiers, statesmen, and scholars; held court in Paris; presided at Princeton; advanced into the Wilderness and then into the White House. Their individual triumphs made this exclusive party seem above America’s founding sins, and it was forgotten that the former was in fact bound to the latter, that all their victories had transpired on cleared grounds. No such elegant detachment can be attributed to Donald Trump—a president who, more than any other, has made the awful inheritance explicit.
Colin Kaepernick and other athletes have a better claim on the United States’s symbols and their meaning.
President Trump apparently slept on it overnight and woke up early on Sunday morning thinking: “Yes, I will fight a cultural war against black athletes.”
In two Sunday morning tweets, Trump urged a boycott of the National Football League until owners punished players who refused to stand for the national anthem, in protest of police brutality and racial injustice—capping a weekend of taunting and trash-talking that began at his Alabama rally Friday night. He’s now created a situation in which it will seem almost unmanly for black athletes, and not only football players, not to take a knee during the anthem. If they stand for the anthem, they will seem to do so at Trump’s command. How can they not resist?
Thirty minutes. That’s about how long it would take a nuclear-tipped intercontinental ballistic missile (ICBM) launched from North Korea to reach Los Angeles. With the powers in Pyongyang working doggedly toward making this possible—building an ICBM and shrinking a nuke to fit on it—analysts now predict that Kim Jong Un will have the capability before Donald Trump completes one four-year term.
About which the president has tweeted, simply, “It won’t happen!”
Though given to reckless oaths, Trump is not in this case saying anything that departs significantly from the past half century of futile American policy toward North Korea. Preventing the Kim dynasty from having a nuclear device was an American priority long before Pyongyang exploded its first nuke, in 2006, during the administration of George W. Bush. The Kim regime detonated four more while Barack Obama was in the White House. In the more than four decades since Richard Nixon held office, the U.S. has tried to control North Korea by issuing threats, conducting military exercises, ratcheting up diplomatic sanctions, leaning on China, and most recently, it seems likely, committing cybersabotage.
What J.R.R. Tolkien’s classic The Hobbit still has to offer, 80 years after its publication
“In a hole in the ground there lived a hobbit.” So began the legendarium that dominated a genre, changed Western literature and the field of linguistics, created a tapestry of characters and mythology that endured four generations, built an anti-war ethos that endured a World War and a Cold War, and spawned a multibillion-dollar media franchise. J.R.R. Tolkien’s work is probably best remembered today by the sword-and-sandal epic scale of The Lord of The Rings films, but it started in the quiet, fictionalized English countryside of the Shire. It started, 80 years ago in a hobbit-hole, with Bilbo Baggins.
Although Tolkien created the complicated cosmological sprawl of The Silmarillion and stories like the incestuous saga of Túrin Turambar told in The Children of Húrin, Middle-earth itself is mostly remembered today as something akin to little Bilbo in his Hobbit-hole: quaint, virtuous, and tidy. Nowadays, George R.R. Martin’s got the market cornered on heavily initialed fantasy writers, and his hand guides the field. High and epic fantasy are often expected to dip heavily into the medieval muck of realism, to contain heavy doses of sex and curses, gore and grime, sickness and believable motives and set pieces. Characters like Martin’s mercenary Bronn of the Blackwater are expected to say “fuck.” Modern stories, even when set in lands like A Song of Ice and Fire’s Essos that are filled with competing faiths, tend toward the nihilist, and mostly atheist. Heavenly beings are denuded of potency and purity; while the gods may not be dead, divinity certainly is.
More comfortable online than out partying, post-Millennials are safer, physically, than adolescents have ever been. But they’re on the brink of a mental-health crisis.
One day last summer, around noon, I called Athena, a 13-year-old who lives in Houston, Texas. She answered her phone—she’s had an iPhone since she was 11—sounding as if she’d just woken up. We chatted about her favorite songs and TV shows, and I asked her what she likes to do with her friends. “We go to the mall,” she said. “Do your parents drop you off?,” I asked, recalling my own middle-school days, in the 1980s, when I’d enjoy a few parent-free hours shopping with my friends. “No—I go with my family,” she replied. “We’ll go with my mom and brothers and walk a little behind them. I just have to tell my mom where we’re going. I have to check in every hour or every 30 minutes.”
Those mall trips are infrequent—about once a month. More often, Athena and her friends spend time together on their phones, unchaperoned. Unlike the teens of my generation, who might have spent an evening tying up the family landline with gossip, they talk on Snapchat, the smartphone app that allows users to send pictures and videos that quickly disappear. They make sure to keep up their Snapstreaks, which show how many days in a row they have Snapchatted with each other. Sometimes they save screenshots of particularly ridiculous pictures of friends. “It’s good blackmail,” Athena said. (Because she’s a minor, I’m not using her real name.) She told me she’d spent most of the summer hanging out alone in her room with her phone. That’s just the way her generation is, she said. “We didn’t have a choice to know any life without iPads or iPhones. I think we like our phones more than we like actual people.”
A new film details the reason the star postponed her recent tour—and will test cultural attitudes about gender, pain, and pop.
“Pain without a cause is pain we can’t trust,” the author Leslie Jamison wrote in 2014. “We assume it’s been chosen or fabricated.”
Jamison’s essay “Grand Unified Theory of Female Pain” unpacked the suffering-woman archetype, which encompasses literature’s broken hearts (Anna Karenina, Miss Havisham) and society’s sad girls—the depressed, the anorexic, and in the 19th century, the tubercular. Wariness about being defined by suffering, she argued, had led many modern women to adopt a new pose. She wrote, “The post-wounded woman conducts herself as if preempting certain accusations: Don’t cry too loud; don’t play victim.” Jamison questioned whether this was an overcorrection. “The possibility of fetishizing pain is no reason to stop representing it,” she wrote. “Pain that gets performed is still pain.”
One reason the president cannot resist commenting on every issue in American life is that he seemingly cannot stand the actual work of American politics.
In a flurry of comments historically unsuited to any head of state, yet hardly shocking for the current American president, Donald Trump this weekend targeted the two most popular sports in the country and elicited sharp criticism from some of their most important figures.
On Friday, Trump encouraged franchise owners in the National Football League to fire players who protest during the national anthem. “Wouldn’t you love to see one of these NFL owners, when somebody disrespects our flag, to say, ‘Get that son of a bitch off the field right now, out. He’s fired,’” the president said at an Alabama rally.
Trump’s comment provoked Roger Goodell, the typically reticent commissioner of the NFL, to issue a strong statement condemning the president’s divisive language. The comment was particularly surprising, since most NFL owners who elect the league commissioner are staunch Republicans. Many of the most prominent owners donated to the Trump campaign.
Its faith-based 12-step program dominates treatment in the United States. But researchers have debunked central tenets of AA doctrine and found dozens of other treatments more effective.
J.G. is a lawyer in his early 30s. He’s a fast talker and has the lean, sinewy build of a distance runner. His choice of profession seems preordained, as he speaks in fully formed paragraphs, his thoughts organized by topic sentences. He’s also a worrier—a big one—who for years used alcohol to soothe his anxiety.
J.G. started drinking at 15, when he and a friend experimented in his parents’ liquor cabinet. He favored gin and whiskey but drank whatever he thought his parents would miss the least. He discovered beer, too, and loved the earthy, bitter taste on his tongue when he took his first cold sip.
His drinking increased through college and into law school. He could, and occasionally did, pull back, going cold turkey for weeks at a time. But nothing quieted his anxious mind like booze, and when he didn’t drink, he didn’t sleep. After four or six weeks dry, he’d be back at the liquor store.