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."
When President Obama left, I stayed on at the National Security Council in order to serve my country. I lasted eight days.
In 2011, I was hired, straight out of college, to work at the White House and eventually the National Security Council. My job there was to promote and protect the best of what my country stands for. I am a hijab-wearing Muslim woman––I was the only hijabi in the West Wing––and the Obama administration always made me feel welcome and included.
Like most of my fellow American Muslims, I spent much of 2016 watching with consternation as Donald Trump vilified our community. Despite this––or because of it––I thought I should try to stay on the NSC staff during the Trump Administration, in order to give the new president and his aides a more nuanced view of Islam, and of America's Muslim citizens.
Long after research contradicts common medical practices, patients continue to demand them and physicians continue to deliver. The result is an epidemic of unnecessary and unhelpful treatments.
First, listen to the story with the happy ending: At 61, the executive was in excellent health. His blood pressure was a bit high, but everything else looked good, and he exercised regularly. Then he had a scare. He went for a brisk post-lunch walk on a cool winter day, and his chest began to hurt. Back inside his office, he sat down, and the pain disappeared as quickly as it had come.
That night, he thought more about it: middle-aged man, high blood pressure, stressful job, chest discomfort. The next day, he went to a local emergency department. Doctors determined that the man had not suffered a heart attack and that the electrical activity of his heart was completely normal. All signs suggested that the executive had stable angina—chest pain that occurs when the heart muscle is getting less blood-borne oxygen than it needs, often because an artery is partially blocked.
“No… it’s a magic potty,” my daughter used to lament, age 3 or so, before refusing to use a public restroom stall with an automatic-flush toilet. As a small person, she was accustomed to the infrared sensor detecting erratic motion at the top of her head and violently flushing beneath her. Better, in her mind, just to delay relief than to subject herself to the magic potty’s dark dealings.
It’s hardly just a problem for small people. What adult hasn’t suffered the pneumatic public toilet’s whirlwind underneath them? Or again when attempting to exit the stall? So many ordinary objects and experiences have become technologized—made dependent on computers, sensors, and other apparatuses meant to improve them—that they have also ceased to work in their usual manner. It’s common to think of such defects as matters of bad design. That’s true, in part. But technology is also more precarious than it once was. Unstable, and unpredictable. At least from the perspective of human users. From the vantage point of technology, if it can be said to have a vantage point, it's evolving separately from human use.
Tucker Carlson’s latest reinvention is guided by a simple principle—a staunch aversion to whatever his right-minded neighbors believe.
Tucker Carlson is selling me hard on the swamp. It is an unseasonably warm afternoon in late January, and we are seated at a corner table in Monocle, an upscale Capitol Hill eatery frequented by the Fox News star. (Carlson, who typically skips breakfast and spends dinnertime on the air, is a fan of the long, luxurious, multi-course lunch, and when I requested an interview he proposed we do it here.) As we scan the menus, I mention that I’ll be moving soon to the Washington area, and he promptly launches into an enthusiastic recitation of the district’s many virtues and amenities.
“I’m so pathetically eager for people to love D.C.,” he admits. “It’s so sad. It’s like I work for the chamber of commerce or something.”
The polymath computer scientist David Gelernter’s wide-ranging ideas about American life.
Last month, David Gelernter, the pioneering Yale University computer scientist, met with Donald Trump to discuss the possibility of joining the White House staff. An article about the meeting in TheWashington Post was headlined, “David Gelernter, fiercely anti-intellectual computer scientist, is being eyed for Trump’s science adviser.”
It is hard to imagine a more misleading treatment.
By one common definition, anti-intellectualism is “hostility towards and mistrust of intellect, intellectuals, and intellectual pursuits, usually expressed as the derision of education, philosophy, literature, art, and science, as impractical and contemptible.”
Here is the exchange that I had with Gelernter when I reached out to ask if he would be interested in discussing the substance of his views on science, politics and culture.
A new report explores why those who benefitted from Obamacare’s Medicaid expansion supported the man who promised to reverse it.
Here’s a question that’s baffled health reporters in the months since the election: Why would people who benefit from Obamacare in general—and its Medicaid expansion specifically—vote for a man who vowed to destroy it?
Some anecdotal reports have suggested that people simply didn’t understand that the benefits they received were a result of the Affordable Care Act. That was the case for one Indiana family The New York Times described in December:
Medicaid has paid for virtually all of his cancer care, including a one-week hospitalization after the diagnosis, months of chemotherapy, and frequent scans and blood tests.
But Mr. Kloski and his mother, Renee Epperson, are still not fans of the health law over all. They believed that it required that Mr. Kloski be dropped, when he turned 26, from the health plan his mother has through her job at Target — not understanding that it was the law that kept him on the plan until he was 26.
In response, some GOP members of Congress are attempting to show sympathy for voter concerns.
In their districts this week, Republican members of Congress are facing pushback from angry town-hall crowds over the potential repeal of the Affordable Care Act. Some lawmakers are offering up a degree of sympathy in response, whether by defending the right to protest or attempting to convince voters they understand their concerns.
Republican Senator Tom Cotton told an agitated town hall audience in Arkansas on Wednesday that he wouldn’t deny that “Obamacare has helped many Arkansans,” after a woman said the law saved her life. When another woman insisted she wasn’t a “paid protester,” the senator tried to reassure the crowd that wasn’t a charge he planned to make: “You’re all Arkansans and I’m glad to hear from you,” he said. “Thank you to everyone for coming out tonight, whether you agree with me or disagree with me. This is part of what our country is all about.”
Liberals may need to decide whether to focus on energizing their base or expanding their coalition.
Democratic Senator Claire McCaskill, who is up for reelection in the red state of Missouri in 2018, recently told a St. Louis radio host she may face a primary challenge. “I may have a primary because there is, in our party now, some of the same kind of enthusiasm at the base that the Republican Party had with the Tea Party,” she said during an interview earlier this month. “Many of those people are very impatient with me because they don’t think I’m pure,” she added.
As the Democratic Party contemplates what’s next in the wake of its defeat in the presidential election, liberals may have to decide what matters more: Building a big tent party where far-left voters and moderate centrists can co-exist even if they occasionally disagree on policy and strategy, or focusing on the demands of the party’s progressive base, potentially creating a more like-minded and ideologically rigid coalition in the process.
All in all, the United States has already set more than 2,800 new record high temperatures this month. It has only set 27 record lows.
Most people handle this weather as the gift it is: an opportunity to get outside, run or bike or play catch, and get an early jump on the spring. But for the two-thirds of Americans who are at least fairly worried about global warming, the weather can also prompt anxiety and unease. As one woman told the Chicago Tribune: “It’s scary, that’s my first thing. Because in all my life I’ve never seen a February this warm.” Or as one viral tweet put it:
Neil Gaiman’s remarkable new book has triggered a debate about who, exactly, owns pagan tales.
Myths are funny. Unlike histories, they are symbolic narratives; they deal with spiritual rather than fact-based truths. They serve as foundations for beliefs, illustrating how things came to be and who was involved, but they’re often sketchy about when or why. There’s a brief scene from Neil Gaiman’s new book Norse Mythology that does a remarkable job of capturing just this: the wonderfully nebulous sense of being in illo tempore—the hazy “at that time” of the mythic past. It begins, as many creation myths do, with “an empty place waiting to be filled with life,” but in this instance some life already exists. There’s Ymir, whose enormous body produces all giants and, eventually, the earth, skies, and seas. There’s Audhumla, the celestial cow, who licks the first gods out of blocks of ice. And there are three brothers—the gods Ve, Vili, and Odin—who must devise a way out of this timeless nowhere: