In eye surgery, the doctor’s experience, training are key

We all likely remember the scenes in the film “Willy Wonka & the Chocolate Factory” where Gene Wilder nonchalantly warns, “Stop. Don’t,” as various characters try unknown products and experience unanticipated “complications.” Of course, each instance ends with predictably unfortunate results.

SB 492 – a bill that originally would have authorized optometrists to perform eye surgery – posed a Wonka-esque scenario in which well-meaning “surgeons-to-be” could have been allowed to enter this realm without anywhere near the training they need to do so safely.

Simply put, learning to do surgery requires actually doing procedures on live human patients in sufficient numbers to develop competence.

Over the past year and under the watchful eye of an Assembly committee, representatives of optometry and medicine met to discuss the bill, the first real contemplative discussion of this issue that we believe has occurred in the nation. Key was the committee’s desire to have the process be “data-driven.”

Having participated in all of those many meetings, I will say without hesitation that I believe the optometrists are sincere in their desire to help patients. Unfortunately, as with most things in life, mere desire is not enough.

Simply put, learning to do surgery requires actually doing procedures on live human patients in sufficient numbers to develop competence. Indeed, sufficient numbers are vital to develop the judgment to choose the right procedure and – particularly important — manage complications (including rare ones) that may arise.

To make a long story short, the optometrists ultimately elected to allow the bill – eventually stripped of all references to surgery – to die, preferring not to pass, as they recently wrote to colleagues, “such minor steps [that could] be confused as significant by lawmakers and inhibit [return] efforts next year for more substantive and meaningful changes [allowing] optometrists to practice more fully aligned with their education, training and experience.“

Yet, that would suggest existing experience the data presented during our discussions clearly established they do not currently have. As for developing such experience in the future, when confronted with numbers that medicine might consider barely acceptable and that were grounded in the data presented by both sides, representatives for optometry – even though none of them was legally able to do the surgical procedures being discussed – countered with barely 5% of that amount.

Why might that have been necessary? Well for starters, they were adamant every optometry student graduating from 2016 onward was to obtain all needed experience during optometry school. Unfortunately, because a given school graduates 60-90 students per year (compared with only 4-8 residents in an ophthalmology program) the data strongly suggested schools would be hard pressed to provide each student with even one surgical case on a live human patient for each type of procedure authorized by the legislation.

Rather than recognize the inability to credibly train that many people, however, the optometrists seemed to let their ambition – for lack of a better word — blind them and proposed “laboratory” experience (e.g., doing procedures on inanimate models) as potentially a wholesale substitute for what patients almost certainly would consider “real” experience.

In fact, a poll of 800 Californians by JMM Research found only 6% were comfortable lowering the number of procedures required to be certified to do eye surgery to the 20 or so in the optometrists’ counter-proposal, and this rose only slightly to 20% if the number was 120 – six times larger. Indeed 65% of those surveyed actually resisted any reduction from the 500 on average currently performed by ophthalmologists.

Under intense scrutiny from legislators, the optometrists slowly inched up the required numbers and suggested they would all be on human patients. Yet, even those numbers remained a small fraction of the training ophthalmologists receive to do the same procedures, particularly when it comes to laser surgery, and woefully inadequate to actually see and treat complications.

In their message, they went on to say they “believe legislators will be true to their word and open to genuine discourse next year” – a discourse we remain willing to continue in good faith. But until training standards for any surgical privileges become meaningful and substantial and under appropriate regulation to allow them to be performed safely, we would ask legislators to recall Wonka’s warning to young Violet Beauregarde as she started chewing a piece of gum that ended up having the unanticipated “complication” of turning her into a giant blueberry: “Oh! I wouldn’t do that. I really wouldn’t.”
—
Ed’s Note: Dr. Craig Kliger is a board certified ophthalmologist and Executive Vice President of the California Academy of Eye Physicians and Surgeons