GUEST EDITORIAL

Scope of Practice: A Threat to the Vitreoretinal Specialist

Retinal physicians need to enter the fray in the fight against expanding optometrists' prescribing rights.

Stephen G. Schwartz, MD, MBA • Harry W. Flynn, Jr., MD

Traditionally, vitreoretinal specialists have been relatively insulated from optometric scope-of-practice battles, but it is time for our subspecialty to take a more active role in these affairs. We are confronted with many patients with complex diseases (including noninfectious posterior uveitis, endogenous endophthalmitis, viral retinitis, etc.) in which early recognition, appropriate testing and targeted therapy are critical.

In most such patients, “shotgun” systemic antibiotics from optometrists will not work, and knowledge-based experience from ophthalmologists will achieve more favorable outcomes. As we evolve away from scleral buckles and large-gauge vitrectomy and toward smaller-gauge transconjunctival surgery and office-based injections, we must pay closer attention to this threat to our patients and our profession. State and national optometric associations are spending large and increasing sums on lobbying efforts, and their efforts have resulted in an impressive string of victories.

	Stephen G. Schwartz, MD, MBA (left), is associate professor of clinical ophthalmology at the Bascom Palmer Eye Institute.
	Harry W. Flynn, Jr., MD (right), is professor and J. Donald M. Gass Distinguished Chair of Ophthalmology at Bascom Palmer. Dr. Schwartz can be reached at SSchwartz2@ med.miami.edu.

A STATE-BY-STATE FIGHT

Currently, 46 states allow, with various limitations and oversight, at least some optometric oral prescribing. Two states, Oklahoma and Kentucky, allow at least some optometric laser and incisional surgeries. And on February 10, 2012, Miguel A. Machado, MD, a neurosurgeon and the president of the Florida Medical Association (FMA), announced that the FMA had reached a compromise with the Florida Optometric Association that would, if passed by the state legislature, effectively grant optometric oral prescribing privileges for the first time in the state's history.

The FMA's negotiations, led by a urologist, were conducted without the knowledge of, and against the express wishes of, the Florida Society of Ophthalmology. The proposed formulary would include acetaminophen with codeine (a narcotic), ciprofloxacin (which has a “black box” FDA warning), acetazolamide and other agents associated with serious systemic toxicities.

In explaining his decision, Dr. Machado wrote, “I made it clear to [the FSO leadership] that they needed to dramatically increase their legislative and political involvement or else they were at risk of losing their battle with the optometrists.”

Let us be clear: this is not “their” — meaning “our” — meaning “ophthalmology's” – battle. This is a battle facing all medical doctors. Midwives, nurse practitioners, chiropractors and many other groups are watching very closely. We did not choose this battle, but nonetheless we are obligated to fight it. Our patients, and our profession, are depending on us. If we do not speak up in defense of our patients, who will?

Dr. Machado continued, “I also told [the FSO leadership] that they had a problem within their own ranks with many ophthalmologists supporting the optometrists' position … there is a split within the ranks of ophthalmology, with more ophthalmologists sending letters to legislators in support of optometrists prescribing oral medications than from ophthalmologists sending letters in opposition.”

Regrettably, this statement appears to be true. We do not wish to discuss our “bad apples” here, other than to note their existence and to provide some food for thought.

The optometrists have several important advantages. They outnumber ophthalmologists by at least two to one: According to the US Bureau of Labor Statistics, there were approximately 34,800 optometrists in the United States in 2008, compared to only roughly 15,000 ophthalmologists. The general public is uncertain about the differences between the two groups: In a 2010 survey, only 71% of respondents identified ophthalmologists as medical doctors, while 54% of respondents identified optometrists as such.

In addition, only 51% of respondents agreed that it is “easy to identify” who is and who is not a medical doctor by reading advertising and other marketing materials. Furthermore, many legislators are under increasing pressure to achieve some sort of “compromise,” which usually means granting at least some of the optometrists' requests.

Larry E. Patterson, MD, a Tennessee ophthalmologist, published an “open letter to optometry” in Ophthalmology Management in 2011 that concluded with the following blunt advice to that profession: “…quit while you're ahead. You got therapeutics. You won … [Let's] have a truce. Quit trying to be surgeons.”

We doubt that this advice will be heeded. The American Academy of Ophthalmology is currently tracking other bills that would expand optometric prescribing privileges in Massachusetts, Nebraska, and New York, as well as surgical bills in Idaho, Indiana, Iowa, Kansas, Massachusetts, Nebraska, South Carolina and Vermont. We have generally observed a “ratchet effect,” in which the scope-of-practice expansion always goes forward, never backward.

TIME IS OF THE ESSENCE

It is late, but it is not too late. We call on vitreoretinal specialists to become more active in scope-of-practice issues. Because these battles are typically fought on the state level, it is important that we join, and support, our state ophthalmological societies. This support includes political contributions and, ideally, personal involvement in lobbying efforts.

In addition, the AAO's Surgical Scope Fund collects donations from around the nation and targets them to the states in the greatest need. It is time to join our anterior-segment colleagues.

This fight is coming to us, whether we want it to or not. It is not about turf, and it is not about economic protectionism. This fight is a fight to ensure that patients receive the best and safest care at all times. Together, we can protect our patients and our specialty. RP

This editorial represents the personal opinions of the authors and does not necessarily represent the views of the Bascom Palmer Eye Institute or the University of Miami.