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."
How did Andrew Anglin go from being an antiracist vegan to the alt-right’s most vicious troll and propagandist—and how might he be stopped?
On December 16, 2016, Tanya Gersh answered her phone and heard gunshots. Startled, she hung up. Gersh, a real-estate agent who lives in Whitefish, Montana, assumed it was a prank call. But the phone rang again. More gunshots. Again, she hung up. Another call. This time, she heard a man’s voice: “This is how we can keep the Holocaust alive,” he said. “We can bury you without touching you.”
When Gersh put down the phone, her hands were shaking. She was one of only about 100 Jews in Whitefish and the surrounding Flathead Valley, and she knew there were white nationalists and “sovereign citizens” in the area. But Gersh had lived in Whitefish for more than 20 years, since just after college, and had always considered the scenic ski town an idyllic place. She didn’t even have a key to her house—she’d never felt the need to lock her door. Now that sense of security was about to be shattered.
Hillary Clinton once tweeted that “every survivor of sexual assault deserves to be heard, believed, and supported.” What about Juanita Broaddrick?
If the ground beneath your feet feels cold, it’s because hell froze over the other day. It happened at 8:02 p.m. on Monday, when The New York Times published an op-ed called “I Believe Juanita.”
Written by Michelle Goldberg, it was a piece that, 20 years ago, likely would have inflamed the readership of the paper and scandalized its editors. Reviewing the credibility of Broaddrick’s claim, Goldberg wrote that “five witnesses said she confided in them about the assault right after it happened,” an important standard in reviewing the veracity of claims of past sex crimes.
But Goldberg’s was not a single snowflake of truth; rather it was part of an avalanche of honesty in the elite press, following a seemingly innocuous tweet by the MSNBC host Chris Hayes. “As gross and cynical and hypocritical as the right’s ‘what about Bill Clinton’ stuff is,” he wrote, “it’s also true that Democrats and the center left are overdue for a real reckoning with the allegations against him.”
Should you drink more coffee? Should you take melatonin? Can you train yourself to need less sleep? A physician’s guide to sleep in a stressful age.
During residency, Iworked hospital shifts that could last 36 hours, without sleep, often without breaks of more than a few minutes. Even writing this now, it sounds to me like I’m bragging or laying claim to some fortitude of character. I can’t think of another type of self-injury that might be similarly lauded, except maybe binge drinking. Technically the shifts were 30 hours, the mandatory limit imposed by the Accreditation Council for Graduate Medical Education, but we stayed longer because people kept getting sick. Being a doctor is supposed to be about putting other people’s needs before your own. Our job was to power through.
The shifts usually felt shorter than they were, because they were so hectic. There was always a new patient in the emergency room who needed to be admitted, or a staff member on the eighth floor (which was full of late-stage terminally ill people) who needed me to fill out a death certificate. Sleep deprivation manifested as bouts of anger and despair mixed in with some euphoria, along with other sensations I’ve not had before or since. I remember once sitting with the family of a patient in critical condition, discussing an advance directive—the terms defining what the patient would want done were his heart to stop, which seemed likely to happen at any minute. Would he want to have chest compressions, electrical shocks, a breathing tube? In the middle of this, I had to look straight down at the chart in my lap, because I was laughing. This was the least funny scenario possible. I was experiencing a physical reaction unrelated to anything I knew to be happening in my mind. There is a type of seizure, called a gelastic seizure, during which the seizing person appears to be laughing—but I don’t think that was it. I think it was plain old delirium. It was mortifying, though no one seemed to notice.
From Eve to Aristotle to Sarah Huckabee Sanders, a brief history of looking at half the population and assuming the worst
The picture was striking. The military airplane. The sleeping woman. The outstretched hands. The mischievous smile. The look what I’m getting away with impishness directed at the camera.
On Thursday, Leeann Tweeden, a radio host and former model, came forward with the accusation that Senator Al Franken, of Minnesota, had kissed her against her will during a 2006 USO trip to Kuwait, Iraq, and Afghanistan. In a story posted to the website of Los Angeles’s KABC station, Tweeden shared her experience with Franken. She also shared that photo. “I couldn’t believe it,” she wrote. “He groped me, without my consent, while I was asleep.”
I felt violated all over again. Embarrassed. Belittled. Humiliated.
How dare anyone grab my breasts like this and think it’s funny?
I told my husband everything that happened and showed him the picture.
I wanted to shout my story to the world with a megaphone to anyone who would listen, but even as angry as I was, I was worried about the potential backlash and damage going public might have on my career as a broadcaster.
But that was then, this is now. I’m no longer afraid.
What the United States can learn from protest and political organizing in the Nordic countries.
Liberals in the United States wistfully regard Scandinavia as a kind of social utopia, while conservatives denounce it as a socialist state where government overreach is ubiquitous. Yet across the political spectrum, Americans believe it would be impossible to adopt the Nordic model.
That’s the starting point for Viking Economics: How the Scandinavians Got it Right—and How We Can, Too, a new book from George Lakey, a former Eugene M. Lang visiting professor for issues of social change at Swarthmore College. Lakey, however, rejects that premise, arguing instead that Americans can adapt the Nordic model to fit the United States, reducing the wealth gap and improving the quality of life for all Americans as a result.
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.”
The Netflix show, more than any other Marvel product, explores the idea that the country’s systems are fundamentally broken.
The Punisher, Netflix and Marvel’s new 13-episode drama about a superhero whose superpower is killing people with guns, is debuting in a very different environment to the one the character was conceived in. When the vigilante Frank Castle first appeared in an issue of The Amazing Spider-Man in 1974, the American psyche was more preoccupied with serial killers and mob violence than with mass shooters. Punisher, a former Marine Corps sniper, turned the merciless tactics of organized criminals against them, displaying no qualms about executing gangsters. He employed what amounted to an arsenal of military-grade weapons. His accoutrements were guns, guns, and more guns.
In 2017, a dizzying number of disturbed gunmen have given the imagery and mythology of Punisher an even darker resonance. In October, a mass shooting in Las Vegas left 58 people dead, excluding the perpetrator. A month later, a 26-year-old former member of the U.S. Air Force killed 26 people in a church in Texas. It’s a discomfiting news landscape in which to absorb The Punisher, whose opening credits caress silhouetted weaponry as brazenly as James Bond title sequences undulate around women’s bodies.
The 93-year-old kleptocrat won’t remain the ruler of Zimbabwe for long.
Despite mounting calls for his resignation, Robert Mugabe has vowed to stay on as president of Zimbabwe, further extending his nearly four-decade reign in office. The next 48 hours will be crucial, as Mugabe could be impeached when parliament reconvenes on Tuesday. The unfolding political drama in Zimbabwe remains muddled at best and follows a stunning series of events, including a de facto military coup last week and a historic mass demonstration in Harare on Saturday, in which jubilant citizens marched hand-in-hand with the same military officials who had long abused their rights with impunity.
On Sunday, the momentum towards Mugabe’s probable ouster picked up steam when the ruling ZANU-PF party voted to expel longtime stalwarts, including Mugabe and his wife Grace, who had been leader of the influential women’s league and, until last week, the president’s presumed successor. Emmerson Mnangagwa, a former vice president and Mugabe protégé, was installed as new party leader. Mnangagwa is now expected to assume the presidency and lead a potential transitional authority.
New projects in the shells of former Sears warehouses reveal much about America’s urban history—and its future.
The retail apocalypse has left empty shells of department stores scattered across the American landscape. It’s been especially hard for Sears, the once mighty retailer that now appears to be on its deathbed. But while the ghosts of the chain’s big-box stores haunt suburban and exurban strip malls, a few relics of the company’s past are actually thriving for the first time in decades.
In the 1920s, Sears built several “plants” across the country. These were unfathomably large warehouses and distribution centers with ground-floor stores, built when Sears was primarily a mail-order company. As urban areas suffered and depopulated in the middle of the 20th century, so did these massive buildings. But today, six of the seven remaining plants have been resurrected in the image of the contemporary city. The first wave of rehabilitations came in the late 1990s, when Boston’s plant was converted to the Landmark shopping center and offices, and Dallas’s plant became loft-style apartments. Seattle’s plant, like an imperial palace retooled for a conquering emperor, became the global headquarters for Starbucks.
The CNN correspondent on journalism, hypocrisy, how a Twitter fave can ruin his morning, and why he has a poster of George Wallace hanging in his office
Jake Tapper sometimes wakes up angry. This may be a good thing for America.
Amid the chaos of the Donald Trump presidency, and the deep partisanship that filters through seemingly all aspects of American life in 2017, Tapper is motivated by the same forces that have animated much of his career in journalism. He can’t stand hypocrisy. He can’t stand unfairness. He can’t stop talking about it.
“I recognize that it’s probably a pain in the ass for a lot of people now,” he told The Atlantic. “But it is just who I am.”
“I’m just like, I don’t want any of this to be happening,” he added. “There are so many lies and so much indecency, and I’m not only talking about President Trump. There is just a world of it exploding—and we are, I fear, as a nation, becoming conditioned and accepting of it. And it’s horrific.”