Optometrists See an Opening ~ and Take it

Ophthalmologists looked the other way as optometrists won a wider scope of practice.

I had not thought about it much until then, and had always assumed it was just another alternative medicine option for the sort of people who had abandoned traditional Western or allopathic medical care, and who were generally the sort of folks who carefully read and analyzed astrological data before going out the door to work every morning.

I had pronounced her sore throat and stuffy nose to be nothing more than an immunological annoyance secondary to a transient viral presence. She then offered to examine my irises, even though, she demurred, she was far from being a fully trained iridologist. That was all right, I told her. I remember how it was when I was an intern. I told her to go ahead, and I went into it with my eyes wide open.

She whipped out a magnifying lens and peered at my irises through the glass, back and forth, right to left. "You are under a lot of stress." (So far, so good.) "You have some abdominal distress." (Actually, I did feel a bit queasy.) "You may have a urinary infection." (In fact, I had noted a bit of dysuria and urgency that morning after my fifth cup of coffee.)

I thanked her for the free consultation. She looked a bit skeptical and once again asked if I was sure there was nothing seriously wrong with her and whether I was confident she did not need a prescription for an antibiotic. I mused silently about her inchoate career, and how come she could not have looked in the mirror and figured out what was wrong with herself.

I asked her what she thought the future of her "profession" was. She said that it was quite bright, but hastened to add that iridology was not the be-all and end-all of diagnostic and therapeutic medicine but only a supplement or complement to traditional medical efforts to advance human health care. "You know yourself," she said, "that sometimes you can tell just by looking in a person's eyes how really sick they are."

Well, there is no state board for iridology, and no California Association of Iridologists. But there is an association of people who are traditionally trained in eye care, albeit quite minimally compared to ophthalmologists, who want the state to certify them as competent to diagnose and treat some really big deal eye diseases. They are well-organized and spend a good amount of money to influence politicians and public opinion. They are the California Optometric Association. And now, with the recent passage of Senate Bill 929, they have been granted many of those privileges.

The road to its enactment has been long. It represents but one chapter in the ongoing struggle for organized medicine against the expanding scope of practice for not only optometrists, but also for psychologists, physical therapists, chiropractors and nurse practitioners. In general, the players, or contestants, are professional organizations which represent their constituencies by bringing their arguments to the legislature with sophisticated lobbyists and PAC money.

The slow erosion of the traditionally wide scope of practice for those of us with MD or DO degrees, and the inexorable expansion of the practice privileges of less well-trained health care providers has been a long time aborning.

Forty years ago, the federal government, alarmed by a burgeoning population and a stagnant supply of physicians, threw billions of dollars into expanding established medical schools and building several new ones. The use of "physician extenders" was also encouraged, and programs blossomed to train nurse practitioners and physician assistants.

In certain political circles, there was grudging admiration for medical care systems in the USSR and mainland China, where, we were told, even the tiniest backwater village had access to physician extenders under the direct supervision of fully trained physicians.

I recall being present at a small medical gathering to hear then-Governor Jerry Brown speak about medical care. He was concerned about the accessibility of health care for certain Californians, felt that physician extenders were a good idea, and also trusted in the people/patients to make good decisions about who they wanted caring for them. He said, in essence, that if Mrs. Smith wants to consult a chiropractor for her abdominal pain and rectal bleeding, she has a perfect right to do so, and it may well be that the State of California should pay that chiropractor for his efforts as if he were an MD. Or, if Mr. Jones wanted to see a podiatrist for his severe back pain and foot drop, because he perceived it to be primarily due to a foot-related problem, ditto for the podiatrist.

Governor Brown combined a populist political philosophy with an enduring faith in the people to just naturally know what to do about their health care needs. At about that time, there was a rising tide of skepticism of the benefits and limitations of MD-dominated medical care, and a general demystification of the practice of medicine that continues apace today with the help of the Internet. Brown was saying that everybody knows it is not particularly difficult to analyze and treat most common diseases, and, even if there is something seriously wrong with Mrs. Smith or Mr. Jones, they will no doubt end up in the right hands. Anyway, we all hear every day about people who go through massive, expensive evaluations and treatment regimens at internationally recognized medical centers and still end up maltreated. So why not try this way instead? What's the harm?

Against that background, the California Optometric Association (COA) has been aggressively lobbying for over 10 years to extend its members' licensable rights. The most notorious effort until now was AB 2020 in 1994, made more notorious by the Speaker's office approval of the contrived numerical designation ~ bills are numbered consecutively as they are introduced, without regard for author or content.

That bill would have vastly expanded privileges for optometrists to treat eye disorders, but it was handily defeated by the CMA and ophthalmology organizations. The optometry forces re-grouped, and over the next few years their arguments gained strength by virtue of the ineluctable fact that most other states have given optometrists the right to treat a wide variety of eye diseases.

As a "one issue" organization, the COA was able to raise almost $1.4 million to promote its effort for SB 929. Many old legislative allies of the CMA and the California Academy of Ophthalmology (CAO) were gone, due to term limits and retirement. There may also have been a feeling by organized medicine that things would work out all right, just as Jerry Brown had felt about the lady who went to the chiropractor with her abdominal pain and rectal bleeding.

The CAO led the fight against SB 929, but soon realized that it was inevitable that something was going to pass in favor of the optometrists. In a letter to its members on October 6, Ms. Starr Shulman, Executive Director of CAO, described her organization's decision:

"CAO never agreed that there is a need to expand the scope of optometric practice....CAO's participation in discussions regarding expanded scope, and the decision not to oppose SB 929, were predicated solely on what we believe to be a realistic appraisal of political realities....All the advice we received in Sacramento was that it was extremely unlikely we could defeat another bill..."

"Our choice was to fall on our swords, or to try to negotiate a compromise that would maintain California as a state where optometric practice would be significantly limited, compared to other states."

And so SB 929 was passed and signed by Governor Davis. It is much more restrictive than laws in most other states, but still allows optometrists to diagnose and treat disorders ranging from glaucoma to cellulitis. The CMA and CAO received a lot of criticism for "allowing this to happen." Some say that CMA and CAO communicated poorly as the bill made its way out of committee to the floor of the legislature, and that the full clout of the CMA was applied too late to sway potentially swayable politicians.

As one ophthalmologist with whom I spoke put it, "It's a dismal example of what happens when organized medicine can't get organized."

However one perceives this affair, the general lesson is that it is becoming more and more difficult to convince the politicians, who hold the keys to practice rights and privileges, that physicians are the only ones who can properly and safely diagnose and treat human illnesses. They are the philosophical heirs of Jerry Brown, as we are of William Osler. Who knows where or when or even whether the twain will meet?

By the time it does, I have a hunch that the California Association of Iridologists will want a seat at the table as well.

John.Ostrich@kp.org