Reconsider delegating refraction

Issue: December 2011

To the Editor:

We find the definition of “subjective refraction” as proposed by Dr. Louis Catania in his commentary, “Delegating refraction: technician collects data, doctor performs subjective refraction” (September 2011, page 4), rather interesting, definitely novel and somewhat amusing.

Do any of us really believe that what we always have known as the subjective refraction is purely a technical task devoid of art? Does the subjective testing that is being discussed here lack determination of a near prescription or the assessment of binocular function? To say that every test optometrists do with a patient behind the phoropter is objective and only the determination of a prescription is subjective is an interesting way to skirt most state laws precluding optometrists from delegating subjective refraction.

We would argue that the delegation of refraction in this manner is not in the best interests of our patients. Further, such a practice is blatantly illegal in many jurisdictions, including California. While, as Dr. Catania suggests, it may be in the best economic interest of the doctor (“market forces”), or in facilitating health care reform, we find those justifications unconvincing and unethical.

We would argue further that the delegation of refraction is not in the best interest of optometrists or our profession. Primary Care Optometry News Editor Dr. Michael DePaolis has discussed the importance of refraction in optometry. He states, “…refraction is still the procedure by which patients identify us.” (September 2011, “Decide what refraction means to you,” page 3.)

No one is better at doing a subjective refraction than a competent optometrist. Why would we want to offer our patients anything other than the best possible vision care we can provide? Do we, as optometrists, want to admit that others with less training are perfectly capable of doing the most basic part of a vision examination? We find only one justification for delegating refraction and that is strictly an economic one. This is neither in the best interest of our patients, nor in the best long-term interest of our profession.

Let all of us consider these issues and their possible unintended consequences more carefully before endorsing the delegation of refraction. We have.

Lawrence Thal, OD, MBA, FAAO
Assistant dean and clinical professor
Michael G. Harris, OD, JD, MS, FAAO
Associate dean emeritus and clinical professor emeritus
University of California, Berkeley, School of Optometry

Dr. Catania responds:

Notwithstanding the tone of their letter, I have been friends with Drs. Harris and Thal for many years, dating back to our debates in the 1980s and 1990s about therapeutics for optometry, to which they were opposed. Ironically and sadly, their rhetoric about the evils of delegating data-gathering functions in clinical optometry, a process virtually all other health professions have embraced for more than 30 years, creates a sense of déjà vu back to their 1980s thinking.

Knowing these colleagues for so long helps me know that their hearts are in the right place regarding our profession, but their outdated philosophy of delegation regarding subjective refraction is simply wrong and even hazardous to the optometric profession. Thus, my strong response to their comments is presented in the spirit of professional debate rather than to assail old friends.

In many ways, it is painful to hear their comments, especially categorizing optometrists’ efforts as being “unethical” as they work toward upgrading their refractive care in their patients’ best interest, their “best economic interests” and in “facilitating health care reform.” Coming from academics, labeling progressive optometrists as unethical is insulting and degrading to our profession. Perhaps unethical conduct might be more appropriately associated with elements of our profession hiding behind self-protective delegation laws and regulations that really are supposed to be protecting the public welfare.

Indeed, as the authors state and to which I agree, a good subjective refraction is an art. But it is not the patient answering “yes” or “no” to “Which is better ...?” that is the art of refraction – it is the doctor interpreting that information and making professional judgments and decisions.

Data-gathering is not an art and, given new 21st century refracting technologies that provide such comprehensive and accurate information, collecting it is a technical function that trained support personnel “... far less trained” than the doctor “... are perfectly capable of doing.” Drs. Harris and Thal ask if we, as optometrists, want to admit that. Yes, in fact, most 21st century optometrists proudly “admit that.”

It is sad that Drs. Harris and Thal would continue to promote an outdated, inefficient refracting philosophy to student optometrists and optometric colleagues who must face serious “market forces” about which these doctors are unfamiliar.

They speak about, “... what we always have known as the subjective refraction” and they reduce a valuable, alternative, more current and, perhaps, better way, as “... an interesting way to skirt most state laws precluding optometrists from delegating subjective refraction.” I think they can do better than that for their school, their state and our profession.

Louis J. Catania, OD