The strength of our armed forces depends on the different levels of training, skill and experience of the ranks. There are good reasons why an ordnance mechanic has a different skill set than a cyber operations officer or why a fighter pilot has a unique background from a counterintelligence officer. Our healthcare system is no different: it depends on a highly skilled workforce with the education and training to provide safe and effective care.
Unfortunately, the Department of Veterans Affairs (VA) is taking steps to allow optometrists to perform eye surgery on veterans. The VA recently amended its community care guidelines “Standardized Episode of Care: Comprehensive Eye Care” by removing language that only allows ophthalmologists to perform surgery. Optometrists are an essential part of a veteran’s eye care team, but they are only trained to provide primary eye care – they do not have the medical or surgical training necessary to perform surgery.
Allowing optometrists to perform eye surgery at VA facilities or through the VA Community Care Program means that the first human subject an optometrist performs surgery on could be a veteran. As a veteran and concerned physician, I will not allow those who have fought for our country to be subjected to a lower standard of care than the VA.
There are no shortcuts to performing surgery safely. After 4 years of medical school and 4 years of residency, an ophthalmologist will have performed hundreds of surgeries of varying complexity. These procedures are mastered over 8-10 years through countless hours of surgical cases closely monitored and mentored by board-certified ophthalmologists.
In contrast, optometry school is a 4-year degree program focusing on primary eye care. They are trained to perform routine eye exams and vision tests, prescribe and fit eyeglasses and contact lenses, monitor eye conditions related to diseases such as diabetes, and provide aids for low vision. Training in clinical surgery is not part of the training of the vast majority of students in optometry.
Contrary to some claims in the optometric community, there is no shortage of ophthalmologists in the community who can provide timely laser and scalpel surgery to veterans.
It is therefore baffling to understand why a handful of states – collectively representing approximately 10% of the US population according to the US Census Bureau – allow optometrists to perform laser eye surgery. Researchers found that most Medicare beneficiaries (over 90%) live within a 30-minute drive of an eye doctor. The overwhelming majority of states only allow ophthalmologists to perform surgery because most policy makers understand that comprehensive medical and surgical training is the best way to ensure patient safety.
Additionally, studies have shown that relaxing standards can harm patients. Laser surgery performed by an optometrist makes patients twice as likely to need additional treatment as if the procedure was performed by an ophthalmologist. The same research found there was an 189% increased risk of needing additional laser surgery in the same eye after an optometrist, rather than an ophthalmologist, performed the procedure. Additionally, troubling complications may be underestimated because optometrists are regulated by state boards of optometry, which for most states do not require optometrists to report adverse patient outcomes. ‘they deal.
For all of these reasons, state public opinion polls show widespread opposition to the relaxation of surgical standards. Additionally, there has been intense media scrutiny, which has revealed how the push to loosen standards is more about politics than patient health.
Most recently, patient safety risks weighed heavily on Governor Gavin Newsom (D.-Ca.) when he vetoed a bill that would have allowed optometrists to perform eye surgeries. Newsom wrote: “I am not convinced that the education and training required is sufficient to prepare optometrists to perform the surgeries identified. This bill would allow optometrists to perform advanced surgeries with less than a year of training. By comparison, physicians who perform these procedures must complete at least a 3-year residency program. For this reason, I cannot sign this bill.”
Veterans have enjoyed established, consistent, high-quality surgical eye care for decades. Why change that now? The VA says the changes are intended to improve efficiency and consistency in delivering comprehensive eye care across the VA. But allowing optometrists to perform eye surgeries in the VA would not solve access issues. Although there are regional variations, most Medicare beneficiaries live within a 30-minute drive of an eye doctor. Allowing optometrists with varying education and training to perform these procedures is not the answer. Instead, this change will lower the standard of surgical eye care veterans now rely on. Eye surgery is delicate and requires the skill and judgment that only a highly skilled and experienced surgeon can provide.
The VA should immediately reinstate the guidelines that protected our veterans so they can continue to receive the highest level of surgical eye care from qualified ophthalmologists.
Kurt F. Heitman, MD, is an ophthalmologist in Greenville, South Carolina. He served as a flight surgeon and ophthalmologist in the US Air Force from 1987 to 1991, and is past president of the South Carolina Society of Ophthalmology.
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