1st January 2014
Crisis or Opportunity?
We’ve all heard how aging baby boomers will soon stress our nation’s health system. If you aren’t yet a believer, consider these stats from the American College of Surgeons on what they label an emerging crisis:
- While the U.S. population is projected to increase 17% between 2001 and 2020, the demand for eye health services is expected to increase 47%.
- Between 2002 and 2030, the number of people age 65 and older in the U.S. will double to nearly 70 million.
In addition, the Affordable Care Act is poised to add another 30 million lives to health care rolls.
A Crisis for Ophthalmology
The number of ophthalmology residents has been steady at about 450 per year for many years and is not likely to change. Ophthalmology recognizes it will experience an acute manpower shortage. However, not all eye care services will be affected equally. The aging population won’t significantly alter demand for refractive care, but it will greatly increase the demand for eye disease treatment.
Here are some of the most telling numbers:
- There will be 15 million new patients with vision threatening conditions by 2020.
- Between 1996 and 2006, the actual number of practicing ophthalmologists increased, but the number per capita has declined more than 11%.
- The Bureau of Labor Statistics projects the actual number of ophthalmologists to decrease by 2020, with the most acute shortages in pediatric and neuro-ophthalmology.
If nothing changes, a stable number of retina specialists, many of whom already see upwards of 60 to 70 patients per day, may have to double their productivity. How is that even possible?
An Opportunity for Optometry
Our health care system will need optometry to play a larger role. Here is my vision of our future:
Primary care optometrists will see greater numbers of patients with significant and challenging eye disease. Some of this care has been, and still is, the domain of ophthalmology. But ophthalmology will increasingly become a secondary and tertiary care profession—limited to major surgery and only the most challenging medical conditions.
Here’s why optometry is the solution:
- Thanks to the efforts of prior-generation ODs, we have much of the legal scope of care necessary to treat most ophthalmic conditions. Are some changes needed to our laws? Absolutely. As we have successfully done in the past, legal barriers can and will be overcome.
- Optometry has a thirty-year record of successful treatment of eye disease.
- Our profession has developed an established group of highly experienced optometrists whose practice is limited to eye disease treatment—in many cases no different than non-surgical subspecialist ophthalmologists.
- These ODs are critical as a source of clinical knowledge, education and the practical aspects of eye disease care.
- The comanagement model has proven effective for over a generation.
Collaboration or Control?
In the keynote address to the American Academy of Ophthalmology (AAO) a few years back, Harvey Feinberg, MD stated it frankly—ophthalmology will need to work with optometry to meet the demand. But from the evidence so far, organized ophthalmology’s vision of collaborative care is very different than ours.
In response to Dr. Feinberg’s pointed call to action, the AAO created its Task Force on Eye Care Delivery for the purpose of designing and promoting collaborative care models with other health care professionals including optometrists. In addition, the American Society of Cataract and Refractive Surgeons (ASCRS) created the Integrated Ophthalmic-Managed Eyecare Delivery (IOMED) program to promote a limited form of MD/OD collaboration it calls Integrated Eye Care.
There is good reason to view these initiatives with caution, if not outright skepticism. One ophthalmologist noted a benefit of this kind of collaboration is that “it enables ophthalmologists to establish scope-of-care boundaries.” Comments like this hardly promote interprofessional trust.
This past May the AOA formed an Integrated Eyecare Project Team to provide leadership on how optometry and ophthalmology can work together to meet the coming demand. It is encouraging that the committee includes some of optometry’s most respected and experienced comanagement pioneers, including Dr. Cindy Murrill of Pacific Cataract and Laser Institute. There will be other efforts as well.
But, there are significant differences in the visions of collaboration held by optometry and ophthalmology—especially regarding professional autonomy. Even so, dialogue alone can promote interprofessional trust.
Optometry and ophthalmology can work together and practice cooperatively. Comanagement as practiced at PCLI and other organizations, such as Retina-Macula Specialists in Washington State, has proven to be an effective model for collaborative care.
Are there guiding principles from our experience that can be applied to a larger model of cooperation? I believe so. Here are a few:
- The free and unrestricted exchange of education and knowledge between professions results in better patient outcomes and experiences. Familiarity and interaction creates genuine trust, respect and communication.
- Treating eye and systemic disease is a unique responsibility. It is inherently complex and uncertain and requires rigorous training, disciplined systems of clinical decision-making, and life-long maintenance of skills and knowledge.
- Optometrists provide primary vision and medical eye care at the highest level of their ability. That scope of care is determined by education, training and experience.
- Ophthalmology is uniquely qualified to perform major surgery and high risk medical care.
- In organizations that include ophthalmologists and optometrists, each profession should develop and determine its own governance, credentialing and privileging independent of each other.
- Every profession and professional should be free to adopt and implement new knowledge, skills and techniques.
- Like ophthalmology, optometry’s scope of practice is now too large for us all to be experts at everything we are licensed to do. It is ultimately the ethical responsibility of each practitioner to ask themselves, “Do I do enough of these procedures (or see enough of these kinds of problems) to competently and confidently treat it by myself or do I need assistance?”
- History shows that knowledge advances, spreads and is adopted. Health care professions that began from seemingly incompatible differences typically converge, even while maintaining their independence and autonomy. Podiatry, osteopathic medicine, and allopathic medicine are good examples.
Embrace the Challenge
History has demonstrated that successful professions respond to the challenges of their time. Optometrists providing medical care did not exist 30 years ago. But the need is fast coming and there will be much work to do.
We should be. This is a great opportunity for our profession.