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The PJ Tatler

by
Bryan Preston

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March 7, 2013 - 10:43 am

I spoke with a surgeon who teaches at a major southern university this week on the subject of how ObamaCare is enabling the blurring of lines between eye doctors.

“It is bringing massive, sweeping changes in how health care is delivered and paid for. Optometrists want to be equal to medical doctors. They are positioning themselves to expand their scope” into primary care delivery and even surgery.

“You do not want people who are not trained” in medical procedures to perform them, the surgeon told me. “But optometry schools are positioning themselves to be on a par with medical doctors. To be primary care physicians. Optometrists are positioning themselves to be able to charge as much for services as a medical doctor.”

The fees charged are key to the story. If optometrists and nurse practitioners can get states to see them on a par with MDs, they can charge fees on a par with MDs, and they can expand their practices to take on revenue-generating services that most states do not currently allow them to perform.

“They just don’t know what they don’t know,” the surgeon told me. “They have less training, which will end up costing us more” in health care. How? More highly trained medical doctors with more experience will tend to order less lab testing than less-trained and experienced people will. More testing means more cost. And along with that increased cost, less training will lead to more errors.

Dr. [David] 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 surgeon I spoke with added: “They want to cut on eyelids and they want to use needles to inject in and around the eye. They want to manage complex disorders of the eye. They want to prescribe systemic medications like anti-viral oral medications for viruses, specifically for shingles, which people can get in their eye and can require corneal specialists. But once again, they haven’t seen those kind of patients, they haven’t managed those kinds of patients. You can’t do a refresher course when you haven’t had the basic course.” The surgeon added that less-trained doctors and nurse practitioners can end up removing objects that should be biopsied for cancer, but due to a lack of training, no biopsy is done.

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All Comments   (21)
All Comments   (21)
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I am not a doctor, but my impression is that every surgeon and internist professor was stories about how the dumb internist/surgeon missed somethign and how the other specialty saved his life at the last second.
1 year ago
1 year ago Link To Comment
I've always used optometrists in the US. Here in Israel, they are very different - optometrists only check vision, and opthomologists - here simply called "eye doctors" - only check modical issues and do not do perscriptions. The former is free only if you buy a pair of glasses, the latter is paid by your health fund (Israel's weird combination of insurance and socialized medicine).

Nurse practitioners and Physician's assistants were already taking over. The overwhelming beauracracy existing in medical offices before ObamaCare really needs to be dealt with; unfortunately ObamaCare is in the wrong direction.
1 year ago
1 year ago Link To Comment
I'm unsure if your misstatements are deliberate but for anyone interested, here is a typical optometry curriculum: http://www.uab.edu/images/optoimg/PDFs/2009catalog.pdf

**Basic sciences are generally the same for medical, optometry and dental schools.
**An ophthalmology residency(where they learn what they do every day) is 3 years and not 15. Some do sub-specialize via a 1 and less often 2 year fellowship.
** The horrific future you predict has already occurred in several states and with no increase in malpractice premiums (ie no significant bad outcomes).
**Early acceptance (after 3 years of college) is permitted in medical, dental and optometry schools but is very rare for each.

I often wonder the rea$$$$$$$$on($) nurses and the lay public are taught to hate optometry and not dentists ??? As you can see, the differences aren't really as vast as say those between a yellow journalist and a PA or optometrist or dentist and the shift toward primary care is very beneficial and cost effective in ALL cases. Try to find a specialist in a rural area of my state !!

I apologize for pointing out what an obvious dumb ass your source made of you - or maybe it was your agenda anyway. Be sure to see a neuro-surgeon if this gives you a headache.

1 year ago
1 year ago Link To Comment
It is very easy to find anecdotal evidence of poor care or even malpractice committed by any class of health care provider. Believe it or not, there are incompetent M.D.s, and there are good ones who are human and make mistakes.

As another comment mentioned, all of the sources in this article are from the M.D. community. In the past, whenever optometrists sought to expand their scope of practice, the voices of doom and gloom were heard from organized medicine. Their fears never materialized. Research that. Look at the big picture, rather than a few anecdotes.

With that said, I don't think that any health care provider should be practicing any type of care that they haven't had sufficient training to do. I share the concerns regarding Obamacare and the threat to the quality of health care. However, this is a biased attack piece that adds very little to a much needed discussion.
1 year ago
1 year ago Link To Comment
Using only ophthalmologists as primary sources and citing cases with only partial or misleading information discredits you rather than bolstering your argument.

"A second opinion from a pediatric ophthalmologist corrected the misdiagnosis, enabling her to get the treatment that she needed."

Victoria Patterson died November 17, 2007, and not because of her optometrist. She had mixed diffuse pontine glioma, an inoperable cancer. The stage of diagnosis unfortunately made no difference in her outcome.

I agree that Obamacare will negatively the quality of heatlhcare delivery, and I am also concerned about primary care being pushed down lower on the provider scale, but this is not good reporting.

1 year ago
1 year ago Link To Comment
I was misdiagnosed by a PA in the ER two years ago. He let me out after admitting that he didn't know what was wrong with me and then recommended that I make an appointment with a cardiac specialist. He was completely wrong about everything, and I ended up in he ER again in a dumpy rural hospital in Hawaii. The PHYSICIAN there knew what was wrong right away. Now I can see what we are all facing. Except the Members of Congress, I suppose, who will get top notch care from physicians.
1 year ago
1 year ago Link To Comment
Background: I am a physician and work part-time with a PA. We have significant interaction with another group that has a PA, two NPs and three physicians.

The idea that competence is conferred with a piece of paper is ridiculous. There are good and bad practitioners in at every point of the "heirarchy". Despite the common perception, it is probably harder to get into PA school than medical school (they are too smart to take on a huge debt load I assume). NP schools are less selective at this time; the top ICU nurses gravitate toward CRNA. The quality control mechanisms are quite different from physicians to NPs/PAs, and that is a definite factor which is glossed over in the argument. Assume the undergrad selection was equivalent. I had a chance to fail out of med school, internship, and residency. I had to pass three national board exams to get just a medical license.

But 99% of the time we will treat similarly! When that happens, maybe it is time to let primary care be run by NPs or PAs.

Whether or not Obamacare remains the law of the land, we need to bend the cost curve and one way of doing that is to use technology to lead us out of the fiscal wilderness. My PA orders tests because my license is on the line and his bad outcomes are more scrutinized, not because he doesn't know what he is doing.

Same handwringing with CRNAs from MDAs, but when we stopped blowing up our pateints with ether, it made sense to let them sit and watch the monitors!
1 year ago
1 year ago Link To Comment
http://www.theatlantic.com/magazine/archive/2013/03/the-robot-will-see-you-now/309216/?single_page=true

Hopefully we can start using technology to keep our kids and grandkids from paying for our guild protection. Do I want to be the "super quality-control robot"? Ugh, but I would do it for my kids to have a future.
1 year ago
1 year ago Link To Comment
You're wrong about NPs. NPs are, first of all, nurses trained to assess, assess, assess. That is what is beaten into nurses' heads. They also have the anatomy and physiology, pathophysiology and microbiology. Granted not as detailed as physicians, but not ignorant, either.

Secondly, NPs are nurses with additional training. Intensive further additional training. NPs can take the place of primary care physicians because they assess, assess, assess, often taking more time and more detail than most doctors do.

PAs have similar training, but not quite as intensive as NPs. They come out of school as PAs without the intensive clinical experience nurses have. That's why they need to attach themselves to a physician or organization whereas NPs can set up on their own.

Both NPs and PAs can do further specialization with further education and clinical training, even doing simple surgical procedures and diagnostics.

If you want good basic medical care and followup, you can't beat an NP.

signed, future NP Midwife
1 year ago
1 year ago Link To Comment
Let's take this one at a time, not necessarily in order.

"Both NPs and PAs can do further specialization with further education and clinical training, even doing simple surgical procedures and diagnostics."

There is no such thing as "simple" surgery or "simple" diagnostics, only simple surgeons and simple diagnosticians.

Assess assess assess means what, exactly?

One of the problems midlevels have is that they may indeed garner a lot of information and that includes, in my experience, ordering far more diagnostic studies and lab tests than physicians do. But assessing is meaningless if you don't have the knowledge to use the information, and discard the useless information, to make a diagnosis.

You are correct...midlevels often "get more detail than doctors and take more time than doctors."

Your unspoken implication is that doctors are lazier and more in a hurry, I gather, than are NP's. The reality is, doctors are far more time and information efficient than midlevels as a direct result of their additional training and experience! A daily frustrations in dealing with NP's and PA's whom I have to deal with is that they present all sorts of information, much of it irrelevant or misleading.

Another way to put it...doctors are far better at winnowing the wheat from the chaff than midlevels. Nothing personal, it is, like the difference between an NP and an RN is time, education and experience.


But if NP's can practice medicine without a physician, then I think they should be judged as physicians...meaning, NP should be held to the same standard. That is not the case. In fact, there are states where a doctor who believes an NP is exceeding their scope of practice and doing things they are not trained to do, cannot bring a complaint against the NP!

Frankly, I don't think the public believes that a NP who claims to be equivalent to a physician, should be held to a lesser standard of care, and I think the public would agree that if an NP is going to claim they are practicing medicine equivalent to a doctor, then doctors should have some oversight as to how they practice, just as doctors have oversight over other physicians practicing medicine. Would you not agree?

I find it ironic that you believe that because you have have additional training and some "clinical experience" (an additional year or two perhaps),you can do things that RN's cannot, because that additional training is important in distinguishing an NP from an RN.

However, it seems that you also believe that the additional training you have as an NP makes you equivalent to an MD, who has had 4-8 years more additional training than NP's have! Why do you so readily discount that training?

If you are correct, and a few months additional training of a nurse equals a doctor, why, we should start closing down medical schools.

The problem I see with many NP's is this. You really don't know what you don't know. Doctors do. It is simply a matter of the time spent in education and training, and doctors have far more of both than do NP's.

There is a place for midlevels, but holding out to the public that an NP or PA is equivalent to a doctor is not true, and a violation of the public trust and professional ethics, which hold that practitioners must know their own limitations and above all, do no harm.
1 year ago
1 year ago Link To Comment
"If you want good basic medical care and followup, you can't beat an NP."

Wow, no blanket statements here. Some of the best, some of the worst like every other profession. This week I have taken four of my patients off a medication prescribed by a NP that was black-boxed four years ago. I have also seen excellent care. When you get done with your training you will alternate between admiring and disowning people you knew in the past. Not everyone who gets the piece of paper lives up to it.
1 year ago
1 year ago Link To Comment
It's good that people are starting to wake up to this. But it is worse than you think.

One of the reasons the government is pushing to legislatively credential health care providers based on it's costs, rather than actual education, is that midlevel providers are, despite many claims to the contrary, literally adrift in seeing patients. The statistics which purport to show that midlevels care is equivalent to physicians is based on a statistical fact...most people who come to see physicians have self limited or non life threatening illnesses. So a doctor, for example, might see 100 people with such a disease and only 1 with a life threatening illness. That statistic holds true for midlevels as well. It's those one in a hundred cases which doctors are vital.

The government bases its success on population based guidelines...if a patient has a good outcome most of the time no matter what provider they see, that's a win for them in their eyes. But if you have that 1 in a 100 illness...tough luck.

In my experience as a doctor...a subspecialist, not primary care...midlevel providers such as NP's have an exceedingly shallow understanding of medicine. They order more examinations than do doctors, in many cases, and have less understanding of results. I find myself fielding calls from midlevels about patient examinations and test results which are unbelievably naive.

The other reason the government is promoting midlevels is that the Electronic Health Record so touted as being a money saver is more and more being used to dictate what care a patient may and may not get, based on population based protocols. Physicians are much more likely to challenge and ignore these protocols than midlevels, who will follow the protocols right into the grave. It is similar to the phenomenon of "Death by GPS" where people drive into rivers they can see, because their GPS map shows that to be the road.

Nothing against midlevels per se, but it is not to the credit of many of the "leaders" in this organization they are pushing to be considered equivalent to a physician, with only a fraction of the training and experience.
1 year ago
1 year ago Link To Comment
Considering the decline in the seriousness of education by medical schools in the past decades, you are far up the creek already.
1 year ago
1 year ago Link To Comment
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