Why do optometrists do things an ophthalmologist should do, and viceversa?

Any thoughts on optometrists treating non-refractive eye problems?

Could any one compare the refraction abilities of an ophthalmologist
vs. those of an optometrist, or are they both equal? And why do they
let optometrists --in the US-- treat things like glaucoma, cataracts,
convergence disorders, accomadation pathologies, conjunctivitides,
etc.? Optometrists should refer their patients to
one who is more qualified to treat them, ie an ophthalmologist. And
why do ophthalmologists refract patients for lenses, or treat low
vision? They too should refer their patients to one who is more
qualified to treat them, ie an optometrist. Both types of eye doctors
have their place in the healthcare system...but they shouldn't do each
other's jobs, it's less productive and could lead to misadventures.

 

Good questions, interesting topic.
I think that ophthalmologists can do all the things an optometrist can
do, i.e. refract patients, because theoretically they have more
training than an optometrist plus the additional training needed for
ophthalmology, therefore they are 'qualified' for anything an
optometrist is. In real terms, though, I think you are right about
optometrists being more experienced with refraction and thereby better
specialized and accomplished refractionists. So if you were to compare
the overall refractive ability of an ophthalmologist versus an
optometrist the latter would be higher. Also, I heard that
optometrists can take additional training mid-way through their career
to give them some of the qualifications of an ophthalmologist, so they
have the legal ability to prescribe and medicate patients with
medicine or eye drops and stuff like that for people with eye
pathologies like glaucoma and cataracts.
You may be right about non-specialized people doing the job that in an
ideal world a specialized person should do, but in the profession I
think there is often a lack of 'ideal', for example all the
ophthalmologists might be too busy dealing with other cases so they
have to let the next best qualified person, i.e. an optometrist, do
the job they would have otherwise done.

 

I meant 'because theoretically they have exactly the same training as
an optometrist'

 

Good question.

I have an eye infection, and went to my optometrist about it, a few days
ago. Why? I've been to him for contact lenses, and I haven't been to an
ophthalmologist, don't know any. Also, he's close, and when I called, they
said I could come in right away, for him to see me.

Whereas, if I went to my family doctor, he is farther away (very significant
that day--as my eyes were so bad, I could hardly open them, probably unsafe
to drive at all, but I had no one to drive me, so at least this drive was
close), and it probably would have been more difficult to get an
appointment.

The optometrist seemed knowledgeable about it, but perhaps an
ophthalmologist would have been better. I don't know. He put me on
antibiotic eye drops (zymar), and of course I'm not wearing my contacts now.
I don't know what an ophthalmologist might have done differently.

It certainly would have cost me less, to go to my general practitioner, as
it would have been covered by my medical insurance, with a $10 co-pay.
Although I have vision insurance, which paid part of the cost for my contact
lens fitting and lenses, I was told at the optometrist's office that my
vision insurance doesn't pay at all for an eye infection, and I had to pay
$65 on the spot, for a few minute office visit.

Not sure if going to an ophthalmologist would be covered by my medical
insurance, or if they only take vision insurance as well. Anyone know? In
any case, as my Blue Cross med insurance is mostly HMO (with some minor PPO
benefits as well), I would probably need a referral from the GP to go to an
opthal covered by med insurance. All that takes time. So, for the benefit of
time (able to go in right away), and nearness to my house (although I'm sure
there are opthals just as near or nearer), it was convenient to go to the
optometrist.

That said, one does wonder if an ophthalmologist would be better-trained in
dealing with something like an eye infection, than an optometrist, and
whether it could have been covered by insurance that way.

 

Sorry, Dr. Tyner, but I did not say that one should wait a week, or that
"optometrists aren't "supposed to" do what they're trained to do".

I actually didn't say any of the things, that you assume I said. You can
read what I actually wrote farther down this message.

I was just wondering about a couple of questions, responding to what Douglas
had written. I did not make any assumptions. And in fact, as I wrote, I DID
go to my optometrist, and as I wrote, I think it was the right choice for
the situation.

Also, not to defend Douglas, whom I don't know, but notice that his post was
not one-sided, as he also speculated that perhaps optometrists were better
than ophthalmologists in refracting patients, and better in prescribing
glasses and contact lenses for them. I don't know if either of his
speculations have any validity--but just pointing out to you, that it was
not one-sided.

I am curious, however, about your statement about insurance. Are you saying
that medical insurance, such as Blue Cross, will normally cover medical care
provided by optometrists? I'll look into that in my medical plan. If that is
the case, however, wouldn't it have made sense for the ODs office staff to
ask what medical insurance I had, or at least to suggest that it might be
covered by my medical insurance, rather than just saying "not covered by
insurance" (meaning the vision insurance)? (They had never asked for info
about my medical insurance.)

 

Just to carry on this discussion a little farther, I have another question.
(And it is purely a question, out of curiosity, I am not making any
assumptions.) (I am not arguing at all here, just asking.)

I doubt you would say that the training, and areas of practice specialty, of
an optometrist and an ophthalmologist, are exactly the same. (If they were,
there would be no need for two different types of eye doctors.

It is clear to me, that your opinion is that in the case of an eye
infection, as I have, that an optometrist is just as well-trained in
treating it, as an ophthalmologist is. You may well be right about that, and
in fact, that is exactly what I did.

However, is there any eye condition that, if it occurred to you personally,
might cause you to see an ophthalmologist for a consultation, rather than an
optometrist?

So again, not making any kind of argument, but just asking---what do you
consider to be the differences between the two types of eye doctors, and for
what kind of condition would you choose one rather than the other?

 

And why do ophthalmologists refract patients for lenses, or treat low

Because it is profitable, especially if they can get the patient to buy the
glasses or contacts from them.

 

For any serious eye disease or injury, you are probably better off with an
ophthalmologist, who has an MD degree. For something simple like a simple
infection (if that is the correct diagnosis) an experienced OD is usually
OK.

In most states a physician's assistant (nurse) can prescribe antibiotics for
most infections (sinus, ear, skin, etc) and the patient may never see the
doctor. Same principle applies to an OD treating eye infections (it is not
rocket science). Of course, if the diagnosis is wrong and there is a more
serious problem, then you might have a more problems with an OD, just like
you might have problems with a nurse trying to treat a serious medical
issue.

A Ophthalmologist does not spend very much time in school learning about eye
care, since their medical school education is much more general (basically
the same training as all other MD's). An OD knows from day 1 when they enter
a School of Optometry that they will be focusing (no pun intended) on eye
care (and the curriculum reflects that), whereas an MD may not get much eye
care training until their residency. So experience (on-the-job training) is
often more important that education in dealing with these matters.

 

I just want to emphasize that part of the problem of optometric
service inclusion has been the lack of a national standard of
licensure for optometrists. What optomerists can treat and the drugs
they can use (formulary) varies by state. Curriculums and training
continually evolve with the times, but laws are slow to change.

Most physicians would love to opt out of the plans. In my area,
finding a dermatologist on our health plan is almost impossible as
most of them are busy doing cosmetic treatments not covered by
insurance. Cosmetic dentistry is another area.

 

Getting OT here, but it would certainly be unfortunate if most physicians
opted out of insurance plans. Medical care is way too expensive for most
people to afford it, without insurance. If most physicians opted out of
insurance, medical care would only be for the wealthy, and many people would
not get necessary health care, as some do not now (who do not have
insurance). With less people getting health care, there would be a rise in
epidemics, etc.

I'm curious--which do physicians find more difficult to deal with--medicare,
or private insurers? (I know this is the wrong forum to be discussing this,
as most ODs tend to deal more with the vision plans, which isn't really what
I'm discussing here. But since we started to discuss the difficulties
physicians have with insurance, I'll carry it a little farther.)

I think most people, including doctors, would agree, that the current US
health insurance system is pretty messed up, and needs some serious reform.
So the question is--what type of reform?

I wonder what people would think of the following? What if, instead of the
plethora of different insurance plans that doctors have to deal with now,
there was (as everywhere else in the developed world), a national insurance
plan, i.e. single-payer? Let's say that that one plan was not anything like
an HMO, but more like a PPO. Or, perhaps, like Medicare, just expanded to
cover all ages?

I'm sure docs would have problems with such a plan as well, as bureaucracies
of all types tend to be--well, bureaucratic! However, wouldn't it be simpler
to deal with only one insurer and plan, that covers everyone, rather than
with the plethora of different insurers, plans, and forms one has to deal
with today? And wouldn't it be nice if there were no more HMOs??

Of course there would still be a role for private health insurers under such
a system, who I'm sure would offer supplemental coverage, as they do with
Medicare, to offer a higher level of coverage above that offered by the
national plan. So, there would still be some dealing with private insurers
as well. But in general, I would think that the paperwork would be simpler
for doctors with a single-payer plan, than the current system, with all its
different kinds of plans, HMOs, etc.

As said, just about all (or I think all) of the rest of the developed world
does have such a system, including Europe, Japan, etc. And one sees that,
once a nation has adopted such a system--no matter what problems they might
have in such a system (of course, nothing created by human beings is
perfect, and especially anything administered by bureaucracy!), and what
reforms are proposed to their system, no country has ever (under
administrations of different political parties) gone back, from a national
single-payer system, to the type we have here in the US. No country has
every abandoned that type of system. Of course problems arise in the system,
they try to improve it, but would never consider in general abandoning the
concept of national health insurance. Even when a conservative party is in
power, no politician would dare propose scrapping a national system, to
replace it with something like ours. So in general, people must like having
such national health systems, even if there are some problems that they wish
to correct, reform, and improve.

Well, I wrote too much, and as I said, it's off-topic for this thread, and
even for the NG. (I guess once I get started on a topic, it's hard to stop!)
Curious to hear other's opinions on this.

 

I'll just add one more point that comes to mind, regarding my recent post
about what people would think of a single-payer health plan, something that
might actually affect optometrists.

How many of you provide health insurance benefits to your office staff? If
you do, I'm sure you are aware of the skyrocketing cost of health insurance
premiums, increasingly difficult for employers to afford, and especially for
small business, like your offices!

Wouldn't it be nice if the government did the insuring (as with medicare),
and employers were not expected to provide such benefits any more, taking it
off your backs?

In fact, that would be good for American business in general. One reason
that U.S. companies are finding it harder to compete with foreign companies,
is the immense amount that U.S. companies have to pay in health insurance
premiums. For instance, the U.S. auto industry--the fact that they have to
pay so much of their income in health insurance premiums, makes it hard to
compete with European and Japanese companies, who don't have to pay a cent
in health insurance premiums--since that is handled by the government, not
by employers.

I'm not saying there wouldn't be costs involved in a national health care
plan. There is no such thing as a free lunch. Of course, taxes would have to
be higher (as they are in those other countries), to pay for the plan.
However, I think the cost involved in the increased taxes, would be much
lower than what is now being paid in private health insurance premiums, cost
of emergency room care for the uninsured, etc. In general, I think the
overall financial cost to society, would be much less than with the present
system, and it would be a great relief for employers, not to have to deal
with providing health insurance for their employees any more. (As well, of
course as the humanitarian boon that everyone would be covered--employed or
not.)

 

Something I forgot to mention, in what I wrote below about the cost of
medical insurance for your office staff.

Since you (O.D.s) are generally self-employed, therefore having no employer
to insure you, I would guess that you are paying extremely high medical
insurance premiums (individual premiums being much more expensive than the
per person cost of group premiums), to insure yourselves and your family
medically. (Not to mention if you or a family member have a "pre-existing
condition"--in which case your premium would skyrocket many times higher!)

How much are you paying monthly overall in medical insurance premiums--for
yourselves, your families, and your employees?

As I wrote, no such thing as a free lunch. If there were a national plan,
and you had no health insurance premiums to pay, you would probably be
paying more in taxes. However--I doubt that the increase in taxes, would add
up to nearly as much, as the amount you are paying now in health insurance
premiums!

 

Opthalmology residency is highly competitive. It requires full 4 yrs
of medical school and an acceptance to an opthalmology residency,
which is an extra several years. Many US med grads do not get accepted
to a single one of these programs.

Optometry training is relatively easy to get admissions to ( < 3.0 gpa
in undergrad ), and is not comprehensive as medical school and
opthalmology residency.

I do not work in visual sciences and can't comment first-hand but this
is something to think about.

The fillings analogy is not a good example. Both general dentists and
oral surgeons undergo the exact same 4 yrs in dental school, where
fillings tend to be the bread/butter in the restorative curriculum.

 

I can speak to your statement since I have been to both medical and
optometry schools. My comments relate to the US health care system,
and there are significant differences in the training and scope of
practice of optometrists around the world.

Optometry school is indeed much more competitive to get into than you
think. The average GPA of the entering class in the school I attended
is ~3.4. The same university's medical school statistics are
similar. The prerequisites for admission to both schools is virtually
identical.

The optometry school curriculum is very similar to medical school
courses during the first two years-- basic science courses in human
anatomy, physiology, biochemistry, pharmacology, etc. The depth,
however, is not as great in some cases as it is in med school. But
optometry students spend considerable time also studying basic optics
and physiological optics to a level that ophthalmology programs or
medical schools simply do not even attempt to match.

IMHO, graduating from a US optometry school gives a person much
greater understanding of the eye than a general ophthalmologist has.
After all, in optometry school 4 years is spent concentrating on a
single organ system. The eye. How much does a med school graduate
really know about the eye-- the answer is, very little. A three year
residency in ophthalmology essentially provides a hands-on
apprenticeship in seeing how surgeons and subspecialists treat certain
ophthalmic conditions but does little to tie it all together, or to
provide for the lack of concentrated study in ocular anatomy and
physiology that is not provided in medical school. I believe that
optometrists get better training in understanding general eye
conditions in otherwise healthy patients who need little more than
eyeglasses or contact lens correction, or treatment of routine medical
problems like infections or abrasions. Such patients constitute the
vast majority of people seeking primary eye care. In short, see
Optometrist for primary health care, go to ophthalmologists for
surgical needs or when referred for complex conditions. Optometrists
can recognize pathologies and refer off to subspecialists as well as
any general ophthalmologist. Personally I think general
ophthalmologists are of negligible value in the US health care
system.

Not to mention that the demographics illustrate that there are
insufficient numbers of Ophthalmologists to meet the primary eye care
to the US population.

I think your understanding of this topic is rudimentary and simplistic.

 

Anybody who really cares can look up the class profiles of any of the
optometry schools and see that your statements are total nonsense.

 

Hello all:

very interesting topic.

we do not have practicing optometrists (own praxis) here in Germany
(not allowed), they work in opticians shops, or hospitals, or
ophthalmology private praxis.

I did not have the time to read every comment thoroughly, but I think
I did not read the following argument, which in my opinion is VERY
important:

Optometrists do not have a general medical education with more than
good lay insight into all other medical subspecialities.
Ophthalmologists have. Bot only education, but individual working
experience.

Finishing medical school / optometric school: of course (!!)
optomentrists are far more experienced in all parts of ophthalmology.

But the final medical student choosing ophthalmology runs through
another 5+++ years of highly specialized training. 5 yrs is the
minimum in Germany, and then you are a General Ophthalmologist, NOT a
corneal, retinal, paediatric, whatever..... specialist, this requires
further training. AND you have the background of a full medical
course, including working (!!) as junior house officer in all the main
and big fields: internal medicine, surgery, paeds, etc.

I agree however that the General Ophthalmologist is probably in spite
of the 5 years less trained in refraction, and low vision device
fitting.

Concerning the eye infection:

1. did the optometrist do a slit lamp examination? Contact lens
wearing problems, corneal ulceration?
2. did he do microbiology (cave: keratoconjunctivitis epidemica is
highly transmissable, and would have meant a sick leave to protect
others!
3. did he do an antibiogramm to check whether these drops are
effective?
4. did he inquire about any other of your health issues?
immunologically relevant diseases?

I don´t quite believe that..... really?

I work in the field of paediatric and neuro-ophthalmology plus low
vision. I do need my general medical knowledge and practical
experience *every day* (including the low vision part! one does have
to know about the general medical, surgical and neurological diseases
affecting the elderly to fit low vision devices correctly!), and I
have studied paediatrics, medicine of the aged patient and much
genetics on my way as well.

You never know what you do not know if you do not know.......

greetings,
Barbara

(Consultant of Paed., Neuroophth, Low Vis., university-based)