Scott A. Edmonds, OD, FAAO, focuses his blog on the role of the optometrist in health care reform – moving from primary eye care to primary health care. He is the chief medical officer of MARCH Vision Care, the co-director of the Low Vision/Contact Lens Service at Wills Eye Institute in Philadelphia and a member of the Primary Care Optometry News Editorial Board. 

Disclosure: Edmonds is a consultant for March Vision.

'Be neither fish nor fowl'

This wise saying has roots that go back at least to the 15th century. It has been applied in many different contexts but applies today as good advice to optometrists attempting to navigate the waters of health care reform.

As optometrists transform to primary health care providers, they will be wise to not attempt to convert their practice to any other practice model but to gather a little of each while maintaining their unique identity as doctors of optometry.

To be more specific, as optometrists have gained medical and minor surgical privileges over the past 30 years, there has been a temptation to adopt the practice model of an ophthalmologist. Some optometrists and even some optometry training programs have minimized the functional and optical aspects of the profession to allow for a more medical mode of practice.

The ophthalmology model of practice, however, is surgical based, and optometry practices that move too far in that direction often fall short of a successful business model. In addition, patients evaluated with the pure medical eye philosophy often have symptoms of eye stain or asthenopia that cannot be diagnosed or managed at the slit lamp. Eye glasses that are prescribed without consideration of functional binocular vision or occupational and vocational concerns often end up in the “re-grind” bin.

To the followers of this blog, you have often heard me advise that optometrists must practice more like physicians. I have urged our colleagues to learn and practice more systemic medicine and address chronic medical problems such as diabetes, hypertension and hyperlipidemia. This is still my advice, but I must temper this with today’s thoughts that I do not want to see our profession convert to become primary care physicians that also happen to prescribe glasses and contact lenses.

As optometrists prepare for practice in the era of health care reform, they must provide medical eye care at the level of an ophthalmologist and primary health care for chronic medical conditions at the level of a physician while not becoming either and maintaining their unique role as an optometrist. This means providing eye examinations that are truly comprehensive by evaluating the physical and functional aspect of the eye while considering the overall health and well-being of the patient.

Today’s modern equipment makes this task much easier than in historic days of optometry in the last century. Our patient today has a technical work-up that includes a comprehensive history, vital signs, autorefraction, autokeratometry or topography, autotonometry and a retinal scan. With all this loaded into the electronic health record and the digital phoropter, it does not take much time to complete the doctor-required components and get on to the real “doctoring “of the eye exam. This doctoring is not the same as would be provided by a physician or an ophthalmologist but a unique blend of elements from these professions that complement the science of vision and visual function that have always been the heart of optometry.

Health care reform has dictated that eye examinations are an essential health care benefit. HEDIS scores have always required elements of eye care, and two of Medicare’s measures for “star rating” require an eye examination.

So, to translate the wisdom of the ages – “Be neither fish nor fowl” – be neither physician nor ophthalmologist. Be an optometrist!