BLOG: Medical specialties in optometry – a vision of true OD-MD collaboration
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Like every optometrist, we were educated to be generalists. Yet, by both residency training and career choice, our expertise has deepened in a narrow area of eye care to where neither of us has performed in many years the defining skill of our profession – refracting and providing an eyeglass prescription.
As specialists in a primary care profession, we can’t help but wonder: What exactly is optometry in 2019? More importantly, given the future health care needs of society and the trends in how that care is likely to be delivered, what role – or more accurately, roles - do we want our profession to play? What would that look like? How do we get there?
In this entry in our blog, we hope you will indulge us to take stock, be a bit audacious and imagine a vision for the future.
As optometrists in a surgical and medical referral center, we have a perspective on our profession that’s different than if we practiced primary eye care. From this position, we think this could be a golden moment to secure the future of optometry. But we as a profession need to design and take control how we get there.
Demand and supply
We’ve all heard how the aging baby boomers will soon stress our nation’s health care system. If you aren’t yet a believer, consider these statistics that cause the American College of Surgeons to label this “an emerging crisis”:
- The U.S. population is projected to increase 17% between 2001 and 2020. The demand for eye health care services is expected to increase 47% (HHS).
- Between 2002 and 2030, the number of people age 65 and older in the U.S. will double to nearly 70 million (U.S. Census Bureau).
Importantly, these projections don’t include the millions of lives added to the health care roles because of the Affordable Care Act.
Here is an important fact for optometry: The aging population won’t significantly increase the demand for refractive care, but it will greatly increase the demand for eye disease treatment. In just the 7 years between 2013 and 2020, there will be 15 million new patients with vision-threatening conditions (Klein et al.). Those numbers will increase significantly more in the future.
Here is some additional interesting information:
- The number of ophthalmology residents enrolled in teaching programs in the U.S. has been steady at about 450 per year for a long time and is not likely to change (Association of University Professors of Ophthalmology).
- If nothing changes, retina specialists may have to double their productivity despite the fact that many already see upwards of 60 to 70 patients per day. How is that even possible?
The bottom line is this: ophthalmologists alone can’t care for the future explosion of patients with eye disease. They can’t even take care of it all now. And they know it.
Ophthalmology proposes collaboration
Several years back, Harvey Feinberg, MD gave a frank keynote address to a skeptical, even resistant, audience: the members of the American Academy of Ophthalmology. His message? Ophthalmology will need to work with optometry to meet this demand.
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 created the Integrated Ophthalmic-Managed Eyecare Delivery program to promote a limited form of OD-MD collaboration it calls integrated eye care.
There is good reason to view these initiatives with promise and caution. One ophthalmologist noted a benefit of this kind of collaboration is that, “it enables ophthalmologists to establish scope-of-care boundaries.” Still, while there may be significant differences between the vision of collaboration of optometry and ophthalmology, especially regarding professional autonomy, dialogue can promote interprofessional trust.
An alternative vision of collaboration
It will be a challenge for the current number of ophthalmologists to just keep up with the increasing demand for surgery. We agree with Dr. Feinberg: Optometry will need to play a much larger role in eye disease management. From our perspective at the referral center, the primary care optometrist will need to manage an increasing number of patients both with routine but also significant and challenging eye disease. Again, to be frank: The demographics don’t lie.
But there will also be an increasing need for optometrists trained to perform only subspecialty medical care and surgical perioperative care for complex surgery that, unlike cataract and refractive surgery, is rarely comanaged with the referring primary care optometrist. And what about ophthalmology? It will increasingly become a secondary and tertiary care profession, limited to major surgery and only the most challenging medical conditions.
The most common model of OD-MD practice has been a small number of optometrists providing primarily refractive and well-care examinations with a larger number of ophthalmologists. We support a different model, the continued development of specialist optometrists to provide secondary-level medical care, not primary care, practicing as a team with the glaucoma, retinal, neuro-ophthalmologist and corneal subspecialist, freeing the subspecialist MD to provide that care for which they are uniquely trained: major surgery and the most complex and highest risk medical care.
What evidence is there that this is needed or can work? Because it already exists. There are already hundreds of ODs who work in subspecialist practices, providing no refractive or routine care at all. They usually have received some form of post-residency fellowship training in their practices of affiliation. Nearly all of these specialty fellowships have been created by innovative and, quite frankly, courageous subspecialist MDs.
We encourage an initiative to create many new OD-MD collaboratively designed post-residency specialty fellowships in retina, glaucoma, cornea and external disease as well as other areas. These fellowships should be standardized, rigorous and demanding, with the specialty skills and knowledge measured and mastered that reflect true expertise and authority. The patient need is there. And optometry can fulfill it.
Eight guiding principles of true collaboration
Are there guiding principles that can be the foundation to a true model of OD-MD collaboration? Here are eight:
- The free and unrestricted exchange of education and knowledge between professions results in better patient outcomes and experiences. Familiarity and interaction create 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 lifelong maintenance of skills and knowledge.
- Optometrists will primarily 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. Yet, we will need to be able to do even more than most of us currently do to take care of the need. 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 and osteopathic medicine and their relationship with allopathic medicine are good examples.
History has demonstrated that successful professions respond to the challenges of their time. Those of us who work in subspecialty referral centers have a particular responsibility to work with the schools and colleges of optometry and our professional leadership to offer more residencies, fellowships and training programs. The need is now.
References:
Association of University Professors of Ophthalmology. Ophthalmology Residency Match Summary Report 2019. Accessed October 14, 2019.
HHS. Physician supply and demand: Projections to 2020. Posted October 2016. Accessed October 14, 2019.
Klein BEK, et al. Invest Ophthalmol Vis Sci. 2013;doi:10.1167/iovs.13-12782.
U.S. Census Bureau. Older people projected to outnumber children for first time in U.S. history. Revised October 8, 2019. Accessed October 14, 2019.