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Medical Forum / General / Vision / July 2008Why do optometrists do things an ophthalmologist should do, and vice versa?
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. > Any thoughts on optometrists treating non-refractive eye problems? > [quoted text clipped - 9 lines] > 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. What's the difference between Zymar prescribed by an OD and Zymar prescribed by an MD? Your GP would likely have tried to treat it with erythromycin or tobrex. Medical insurance should pay for medical care. Optometrists provide medical care and most of us are on Blue Cross panels. HMOs make their profit by NOT paying. So you're saying you should have to wait a week because optometrists aren't "supposed to" do what they're trained to do? Optometry schools aren't "supposed" to teach microbiology and pharmacology? Who does fillings better, a family dentist or an oral surgeon? -MT > Good question. > [quoted text clipped - 47 lines] >> 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. 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.) > What's the difference between Zymar prescribed by an OD and Zymar > prescribed by an MD? Your GP would likely have tried to treat it with [quoted text clipped - 63 lines] >>> 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. > 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. Because it is profitable, especially if they can get the patient to buy the glasses or contacts from them. > 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. And I confess to being sensitive. :) > 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? Yes. Many insurers require that you see only the doctors who are on their provider list, and some insurance companies make it very hard for optometrists to become providers, particularly HMOs. In most cases, state insurance commissions will insist that companies include optometrists' services. Only ERISA plans can lawfully exclude optometrists. Medicare is the flagship in this area, and Medicare has covered non-surgical medical services by qualified optometrists for the last 30-odd years. > 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.) There would be some reason. Not many years ago, there were no "vision plans" to speak of, and there are still optometrists who don't participate in _any_ insurance. In most cases you can turn in your bill from that office and your insurance co will treat it as an "out-of-network" claim, which in the case of HMOs probably means they ignore it. The requirements for billing medical insurance are pretty stringent. It is a game. Insurers habitually shave off charges and "disallow" services and and create paper mazes (now electronic mazes) that are more work than many doctors want to fool with, even MDs. Many medical doctors are opting out of major medical plans like Medicare for just this reason. IF you get all the i's dotted and t's crossed, they MIGHT pay you 80% of what THEY think your services are worth. When you get your money (30-60-90 days later), they sometimes come back a year or two later after deciding "Oops, we paid you in error. Send us that money back or we'll hold it out of your next check." Never mind that you've already refunded the money to the patient. Many optometrists have never signed up with medical insurers, just like many medical doctors are dropping out of it. Stay tuned for my next rant - "Oh, so you think HIPAA is about PRIVACY?" -MT > Yes. Many insurers require that you see only the doctors who are on their > provider list, and some insurance companies make it very hard for [quoted text clipped - 3 lines] > the flagship in this area, and Medicare has covered non-surgical medical > services by qualified optometrists for the last 30-odd years. 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. On Jul 13, 9:05am, "Mike Tyner" <mty...@mindspring.com> wrote: >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 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'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! > 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 [quoted text clipped - 25 lines] > well, of course as the humanitarian boon that everyone would be > covered--employed or not.) > Optometry schools aren't "supposed" to teach microbiology and > pharmacology? 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? > 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 [quoted text clipped - 16 lines] > 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? 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 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. No. But the principle difference is that OMDs (MD ophthalmologists) spend a lot of time learning general medicine and surgery. In the school I attended, the optometry program was very much like dentistry, sharing many of the same lecture halls, instructors and curriculum with dental students for the first two years. > 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. Not every optometrist, and not every infection. There are some infections nobody wants to treat, and even general OMDs will refer those to corneal specialists, for instance. > 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? If I suspected I had acanthamoeba, I'd beat a path to the corneal specialist. So would my cataract surgeon, if he had it. > 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? Generally you go to a surgeon for surgery. -MT > So you're saying you should have to wait a week because optometrists aren't > "supposed to" do what they're trained to do? Optometry schools aren't > "supposed" to teach microbiology and pharmacology? > > Who does fillings better, a family dentist or an oral surgeon? 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. On Jul 13, 6:10 pm, infinitec...@hotmail.com wrote: > 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 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. On Jul 13, 5:10 pm, infinitec...@hotmail.com wrote: > > So you're saying you should have to wait a week because optometrists aren't > > "supposed to" do what they're trained to do? Optometry schools aren't [quoted text clipped - 17 lines] > oral surgeons undergo the exact same 4 yrs in dental school, where > fillings tend to be the bread/butter in the restorative curriculum. Anybody who really cares can look up the class profiles of any of the optometry schools and see that your statements are total nonsense. >The fillings analogy is not a good example. Both general dentists and >oral surgeons undergo the exact same 4 yrs in dental school And after 4 years, both of them are allowed to provide medical care within the scope of their training. So if optometry students endure the same four years, share the same basic sciences curriculum and get comparable specialty training, they should likewise be allowed to provide medical care within the scope of their training. -MT 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: > 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 [quoted text clipped - 5 lines] > 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. 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? > 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. 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) |
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