Optometry’s first licensure law, passed in Minnesota in 1901, is emblematic of the profession itself. Not just because of the historical precedent it set, but because of how frequently it was challenged, restored, disavowed, reinstated and updated. The 1901 bill was rewritten in 1914, 1924 and as recently as 2008.1 That’s the story of optometry in a nutshell—a profession constantly redefining itself.
First, optometry fought tooth-and-nail to distinguish itself from medicine. Then, it fought medical disciplines from encroaching on its refraction work. Next, it insisted it was a medical discipline itself and that its practitioners were, in fact, doctors. Today, optometrists are circling the wagons around laser and minor surgical procedures as well as injections, so perhaps it’s time for Minnesota to dust off that vintage 1901 bill for yet another update. Optometrists in Oklahoma, Kentucky and Louisiana already have their laser privileges.
In 1937, Reader’s Digest put optometry “on trial” by challenging its clinical skills and professional ethics.2 But, in a sense, optometry has always been on trial, and has had to fight to justify its existence to the medical establishment, the public and the law. Each time its champions advocate for expanded privileges, optometry returns to the court of public opinion and academic scrutiny. But it’s learned to navigate the rocky, perilous waters of legislation. This profession, it seems, attracts the underdog. It’s got something to prove to its foes. Luckily, as Matt Garston, OD, of New England College of Optometry puts it, “They have to win every time out. We only have to win once.”
This is the story of optometry’s persistence in getting that “one win” that counts.
In 1922, The Optical Journal and Review of Optometry (OJRO) reported on a “rollicking dinner, brightened by witty five-minute talks and snappy college yells by the students of the graduating class of the Pennsylvania State College of Optometry.”3 Among the speakers at this boisterous event was the school’s founder, Albert Fitch, who must have already stood as a modern day folk hero to the boys sitting before him. Seven years earlier, Fitch led the charge to pursue legal action against a Pennsylvania judiciary and successfully bucked regulation when optometry was deemed “a separate profession from medicine.”
The OJRO article continues: “Albert Fitch aroused the enthusiasm of the diners when he expressed hope that the 1923 Legislature will give the college the right to grant degrees. Toastmaster Joseph Hagerty intensified their interest by stating that the law committee of the Philadelphia society had already started work on the plans for such a privilege.3 You can almost hear the champagne glasses clinking. A year later, the first Doctor of Optometry graduates would turn their tassels and be handed that very degree.
But those first professional degrees were the culmination of work begun decades, not years, earlier.
Optometry’s first legislative battle would be hard won and take decades to accomplish. Its story starts with Charles F. Prentice of New York. Prentice authored the lead feature article in the very first issue of Review’s predecessor, The Optician in 1891, a clinical piece entitled “A Metric System of Numbering and Measuring Prisms.”4 He had studied physics, optics and engineering in Germany and likely had more expertise in refraction than most ophthalmologists of his day.4 A retrospective piece about him, published in 1969, recalls, “Prentice was a scrapper, almost to the point of ruthlessness. His determined nature and sense of superiority may not have won many friends for him within optometry, but his brilliance and doggedness compelled medical respect and helped to win the day for the non-medical refractionists.”4
Perhaps it was this scrappy attitude that led him to take a leap in 1895 and begin charging a fee for eye exams. At the time, the state of New York considered optometry separate from medicine, but an exam of the eye was itself considered a medical practice. The argument of the day was that optometry was a more serious evaluation of the health of the eye than was provided by a dispensing optician—who merely filled prescriptions—but did not include medical treatment and, therefore, should not be regulated as a medical practice.5 It was a measurement, yes, but of the function of the eye.
Three years earlier, Prentice had tried to establish a legal precedent for refracting opticians in New York so that he could charge a fee for the service.6 “In the early days, a lot of the activity took place in New York State,” explains Ron Ferrucci, OD, current president of the Optometric Historical Society. “A lot of opticians there were doing quite well. They were serious and confident about their skills. They were gaining public acceptance and they finally felt that it was time to legitimize what they were doing in the face of what was becoming increasing criticism from medicine.” Prentice faced challenges on one side from “physicians who wanted optometry to be regulated by the medical profession” and on the other side from “dispensing opticians who did not want refracting opticians to be in the business of dispensing eyeglasses.”6
When Prentice charged the fee in violation of state regulation, essentially practicing medicine without a license, oculist Henry Noyes threatened him with jail time. But change was in the air. That same year, 1895, The Optician took on a new name—The Optical Journal—and established itself as the first optometric publication in the United States. In 1896, Prentice, still enraged at the threat against his freedom, issued a stern treatise on the reasons why states should recognize his profession. He also drafted a bill insisting the government recognize that “fitting glasses constituted the treatment of light, not disease and so did not infringe upon medicine’s purview.”7
Two years later, Prentice would help launch the American Association of Opticians (forerunner of today’s American Optometric Association) along with many like-minded thinkers, including The Optician’s founder, Frederick Boger.8 That year, chapters would open in 31 states.6 They were an army on the rise. A rogue militia bucking established protocol. Fitch was among them. As were H.M. Hitchcock, Alexander Sweningson, C.A. Snell, J.W. Granger and F.A. Upham. They declared the first victory for optometry in 1901 when Minnesota “fell,” and the domino effect soon began. By 1903, organized optometry took Illinois, following a lawsuit that declared, “the selling of spectacles and the treatment of defective vision are not part of the practice of medicine or surgery.”6 In 1915; Pennsylvania was on board (following Marin v. Baldi).6,9 In 1917, the US Supreme Court handed down a decision in the McNaughton v. Johnson case, stating that states may regulate the practice of optometry through licensure.6
Prentice and the Oculists
Believe it or not, Prentice started out as friends with Henry Noyes, MD, and D.B. St. John Roosa—both founders of the American Ophthalmological Society. They met while Prentice was at New York Eye and Ear Infirmary in the late 1880s.1 Dr. Noyes even asked Prentice to present his system of prism measurements to a group of ophthalmologists.1
But in an 1892 letter, Dr. Noyes challenged Prentice’s practice of charging a fee for an exam, calling it an “injustice to the public.”1 Prentice responded that he was as qualified as the “average rising oculist” and always sent disease suspects to a medical doctor. Noyes and Dr. Roosa became enraged at Prentice’s hubris, and Roosa appealed to the New York County Medical Society to cut out optometrists altogether. However, Prentice had better sloganeering; his rallying cries framed the profession not as one of medicine, but of optics: “A lens is not a pill!”2 Lapel pins and advertisements read, “Optometry is founded on optical science” and “A lens treats light. A lens does not treat disease.” All these counteracted the oculists’ argument and helped defeat bills relegating refraction to medical doctors in New York and Ohio in 1896.
Just like that, Prentice had nearly won his revolution. Throughout the 1910s optometry bills were the talk of the trade. Optician pages from this era are littered with headlines such as “Victory Won By Maine Optometrists” or “Hearty Support of New Jersey Bill.”
The Last Stand
A few hiccups remained; for instance, Texas dragged its feet in establishing an optometry act and, there, the question remained: Was optometry a medical practice? If declared as such, Texas could shut down every optometrist for lacking a medical license.
The AOA devised a plot to force the judicial system’s hand.10 In 1919, Fred Baker chose to be arrested for performing an eye exam and charging a fee. After years of lost time, money and aggravation, the case was eventually decided in his favor, and optometry was permitted in the state of Texas—the last state holding out against official adoption.10
Establishing Ethics: 1924-1968“During the first two decades of the 20th century, optometry was faced with the enormous challenge of transitioning from a trade to a profession,” explains Dr. Ferrucci. “This required the establishment of standards and a scope of practice that was recognized and accepted by the public and was unassailable by opponents of optometry. The passage of state laws firmly establishing optometry as a legislated profession was the necessary way to achieve this aim, and all 48 states accepted this challenge with a fervor,” he says.
The era saw an explosion in the development of optometric schools and formal bodies. By this point, each state had an optometric board. In 1925, the AOA formed the Council on Optometric Education (COE) to accredit optometric education institutions.11 As a result of these waves of organization, optometric education flourished over the next decade.11
But the ethics of this hybrid of health services and commerce remained unsolved. How far into medical care should optometrists practice? Should they advertise? What services should be offered at a charge? These questions were on the lips of every optometrist in America and were pontificated upon throughout the pages of this publication, by then known as The Optical Journal and Review of Optometry.
1937 was a momentous year. Franklin Roosevelt had just won re-election in a landslide. (Four years earlier, an illustration of the bespectacled president himself graced the OJRO cover). In Germany, Hitler was secretly plotting the blitzkrieg—perhaps while wearing a pair of reading glasses that he kept so secret, he was rumored to have personally destroyed any photographic evidence of having worn. In Pennsylvania, Fitch was angling—nearly with success—to expand optometry’s scope to include diagnostic and therapeutic pharmaceuticals, a privilege most optometrists wouldn’t experience for more than three decades.12
In an address published in The Optical Journal-Review, AOA president Harry Pine, DOS, drew a line in the sand over the divide between the groups he calls “commercial optometrists” and “professional optometrists.”13 He set the tone with a stern warning to “remove any semblance of commercialism from their places of practice, to have them conform to the highest type of professional practice.”13 Dr. Pine lamented that “during this past year, the professional practice of optometry has been assailed and has been obliged to protect itself against onslaughts waged by those who would destroy optometry as a profession.”13
No sooner had Dr. Pine railed against the charlatans within optometry than a devastating article appeared in Reader’s Digest, “Optometry on Trial,” labeling optometry a sham.2 The article uses some similar language, claiming “optometry has endeavored in the legislatures and in the courts, to stamp out ‘corporate practice’ and often the corporations have won.” In the pages of ORJO, the AOA shot back: “This article contained many untruths and half-truths about the profession.”13 Responses to the article took up more than a dozen pages in The Optical Journal and Review. It was clear optometry suddenly had a huge PR problem.
State laws were already beginning to address this issue. For instance, Michigan amended its law in July 1937 to prohibit “canvassing neighborhoods or soliciting at businesses for the purposes of selling glasses, eye examinations and other optometric services,” as well as “practicing ‘price advertising’ for eyeware (glasses, lenses, frames) or optometric services.14 Steps like these helped legitimize optometry, but, on December 7, 1941, an earth-shattering tragedy would give American optometry the opportunity to serve the country and prove its worth.
In Times of War
In 1942, H.C. Roberts, OD, wrote in The Optical Journal and Review, “Someone has aptly said, ‘Optometry began behind the jeweler’s counter, but it will fulfill its destiny upstairs in a white coat.’ This prediction appears to be coming true.”15
The 1940s represented a decade in which optometry began to shore up its numbers in both education and representation. In 1930, the Council on Optometric Education had already established academic standards for the profession, but in 1941 the Association of Schools and Colleges of Optometry, with Albert Fitch again at the helm as its first president, unified the optometric education leaders. “The Association of Schools and Colleges came on board to unify the optometric education leaders,” says Dr. Ferrucci. “As the educational process continued, optometry became somewhat frustrated that they weren’t able to practice at the limit of their education.”
|OJRO, its advertisers and the optometry field joined in the WWII effort. The war would give optometrists the opportunity to prove their profession’s value, both in the service and, later, in Veterans Administration hospitals.|
When the United States entered World War II, optometrists played their role in the effort. In a May 15, 1943 issue of OJRO, AOA president Ewing Adams, OD, wrote “In time of war, optometry has a special skill which is needed by the armed forces and industrial workers.”16 In 1944 the AOA attempted, but initially failed, to establish an “optometry corps” in the military.9 However, by 1947, optometrists were commissioned in the Army and placed on the staff of Veterans Administration (VA) hospitals.9 These two appointments not only offered optometrists the opportunity to serve their country, but to apply the full extent of their knowledge. The Army and the VA were perfect testing grounds, as treating these patients with greater privileges wasn’t constrained by state statutes.
Following the war, “the GI Bill allowed a number of intelligent, mature, career-minded individuals to enter the profession. Many worked in the medical corps and did many more things as servicemen than they were allowed to do in the practice of optometry at the time,” explains Dr. Ferrucci. “So, in the ’50s, there was a struggle as to where we wanted to go. Did we want to remain a non-medical refracting profession, or did we want to embrace the fact that our education is improving and that we should be doing more for the public welfare? Although there were some rumblings by some that we should move toward ‘the medical model,’ the profession as a whole wouldn’t be ready to move in that direction for at least another decade.”
Always bubbling under the surface was resentment—and attempted sabotage and skullduggery—from the medical establishment. “The 1950s, in my view, is a particularly turbulent time because the profession was conflicted,” says Dr. Ferrucci.
“There was a very famous meeting in Seattle in 1954 where optometrists said, ‘the field of refraction belongs totally to optometry and any other entity who tries to practice this is practicing optometry without a license.’ Medical took umbrage at that, saying, ‘You’re telling us that we medical doctors are not allowed to do refractions?’ So, medicine retaliated, which harmed the interprofessional relations for a time,” he adds.
In Massachusetts, Dr. Garston was one of the young doctors embroiled in some of those very conflicts. In the 1950s and 1960s, “if people would come in with problems, we were only allowed to try to help them with either glasses or contact lenses, and if their vision was still not quite right, we really couldn’t look well enough to really understand what the problem was,” Dr. Garston says. “So, the atmosphere was one of frustration, I think, because we had to refer these cases to ophthalmologists.”
Even so, the field was booming. With acceptance by the VA and an influx of new doctors opening optometric businesses around the country, optometrists must have felt for the first time that they were on a winning streak. But two major blows in the 1960s would remind them their fight was far from over. First, the AOA—hoodwinked by ophthalmology—voted not to be included under Medicare, which would haunt optometrists for years as they lost patients to ophthalmologists. Second, they still lacked the legal right to perform a variety of basic tests, including applying diagnostic drops. “It was felt we should have more of an ability to look inside the eye and to check the pressure of the eye with both dilating and anesthetic drops,” says Dr. Garston.
At this time, an optometrist practicing in a VA facility enjoyed a variety of clinical privileges, but as soon as he stepped outside, he would be relatively powerless to perform those same procedures. Outside, the optometrist could merely “detect” disease and then refer it out to an ophthalmologist for an actual diagnosis. In 1961, optometrists in Pennsylvania introduced a bill that would allow ODs the use of diagnostic pharmaceutical agents (DPAs). But the bill never even came to the floor and it would take another decade before optometrists were granted this privilege.9 Mydriasis-inducing formulations started to creep into optometry from the educational side and from health systems that operated outside of state laws, such as VA hospitals. So, a few were able to use them and started to see not just the benefit, but the need for their use.
“In 1968, I was hired by the college here in Massachusetts and then I was asked to go to the public health hospital in 1969 and that’s where I was asked to use the drugs,” explains Dr. Garston. “It was like before we were looking into a room through the keyhole versus—with the drops—opening the door and doing a better exam. It was a big thing,” he says. “Formerly, we couldn’t tell what the patient’s problem was or what to do about it, so we would just send the patient to the ophthalmologist and usually, they didn’t send them back. It was a one-way street—very frustrating.”
Of course, the medical establishment fought Dr. Garston every step of the way, legally and psychologically. The first time he applied diagnostic drops, he says, he stood on guard ready to catch his patient if he collapsed. “Ophthalmologists were saying these drugs were dangerous and patients could die,” he relates.
His experience was reflected across America—and optometry wasn’t going to take it lying down.
Revolution: 1968-1998Like the American Revolution, the optometric revolution was launched by a small team of co-conspirators. The insurgents sought to address “rumblings and discontent among the younger optometrists who were dissatisfied with the imbalance between the scope of responsibility and educational preparation.”17 By then, “the frustration in the profession was festering and it was coming to a head,” says Dr. Ferrucci. “I think some of these forceful leaders were coming together and said ‘it’s time now, to take the bull by the horns.’
Key players included Drs. William Baldwin, Irvin Borish, Milton Eger, Sprugeon Eure, Alden Norman Haffner, William Hazlett, Gordon Heath, Norman Wallis and others.18 This team sought to address the frustrations of the ’50s and ’60s by establishing optometry’s role, making a concerted effort to be recognized for that role and elevate the profession altogether. The momentous 1968 event—held in an airport hotel adjacent to La Guardia airport in New York—would come to be known as “The La Guardia Conference.”18
“Please, Call Me Doctor”
By Irving Bennett, OD
Twenty-five years ago, in 1991, there were relatively few female optometrists in the United States, and female ODs in leadership roles were even scarcer. So it was quite a surprise when Nancy Wiggins, OD, a young partner in a busy practice in Aliquippa, Pa., became the editor of a weekly eye care column in the daily Beaver County Times.
The column enjoyed a good degree of popularity, and it certainly boosted her practice when the byline read Dr. Nancy Wiggins. But when the Times got a new editor and publisher, things changed. Dr. Wiggins was told that henceforth she could not use the “Dr.” title with her column since she was not a medical doctor. That ended the column, but Dr. Wiggins did not relent.
When I heard about the Times’ policy, I met with Alan Buncher, the publisher, to learn more. I had been active in civic activities in Beaver County for decades; my name was in the paper all the time and I was always referred to as “Dr.” The meeting was cordial but non-productive; he politely explained that the Associated Press Style Book specifically said that the Dr. title was reserved for medical doctors or (in some cases) PhDs. That’s that.
I soon learned the AOA was already negotiating this issue with the St. Louis Post Dispatch and the Associated Press. The AOA’s efforts led to the AP Style Book amendment that gave publishers the choice to list optometrists, and other non-MD professionals with doctorate degrees, if they wished. Mr. Buncher called to tell me the local paper would now list optometrists as doctors.
The word “doctor” comes from Latin and is synonymous with “teacher.” It had been usurped by medicine years ago, and its use went unquestioned. It was not until 1923, when PCO founder and president Albert Fitch single-handedly arranged for a bill to be introduced in the Pennsylvania Legislature to permit PCO to award the Doctorate of Optometry degree to its graduates.
The bill was met with skepticism, and many optometrists expected it to be summarily defeated. They also feared retaliation from the medical profession and educators. Surprisingly, there was no opposition from either educational or medical circles, and Pennsylvania welcomed the first US law legalizing the OD degree.
Organized medicine did not oppose the effort because, as Fitch tells it in his autobiography, medicine was proposing legislation in Pennsylvania that would amend the Optometry Act to require that a candidate for examination for licensure in optometry be “a graduate of a school or college of medicine and surgery.” Medicine was confident that this proposal would be adopted, eliminating optometry as a profession. Thankfully, the bill never was passed!
Over the years, ophthalmology branded optometry by defining it for what it was not instead of what it is. The phrase, “optometrists are not medical doctors,” got widespread distribution and even today it is sometimes still used to define optometry.
A 1969 controversy stemming from a “60 Minutes” story about the Cyrus Bass lawsuit against the AMA highlights how the media perpetuated this branding. Dr. Jack Runninger wrote to CBS complaining about the unfair reference in the “60 Minutes” story defining optometry. Nationally-recognized journalist Andy Rooney responded in part, “I must disagree with you about use of the word ‘doctor.’ There are no legal restrictions to its use, but the word has gained its stature from its association with the medical profession […] (optometrists) are intentionally borrowing some of the meaning which the medical profession has given the word and are therefore being just the tiniest bit deceptive.”Today, however, everyone accepts optometrists as doctors just as they accept dentists and podiatrists—thanks to the to the AOA and the dedication of stalwart optometrists of yesteryear.
The Triumph of DPA legislation
It was at La Guardia that optometry first planted a flag in the ground. In his address to the group, Dr. Haffner declared, “the optometrist is a primary care provider and the optometrist has a role in the diagnosis and treatment of ocular pathology.” He rejected the idea that this encroached on medicine, saying, “the experience of dentistry and podiatry disclaims that argument emphatically. Ophthalmology may well ask the question of the future of its own discipline. It seems to me that the medical and surgical skills of ophthalmology might be turned to include the other critically needed special talents in neurology, neuro-ophthalmology and internal ocular surgery.”18
From this meeting came three primary conclusions about advancing the profession. First, optometry must abandon its self-image as a drugless profession. Second, optometrists must take a tip from medicine and continuously update their education to elevate the profession, in the public’s eye, to that of a primary care provider. And third, just as Prentice had done at the turn of the century, they must organize to update optometric legislation. Later meetings would bolster the decisions made on this day, such as the Airlie House Conference held in Warrington, VA, in February 1969, where ODs laid out specifics on how to enact diagnostic pharmaceutical agent (DPA) legislation.19
Following La Guardia, Dr. Haffner and others took the message near and far. It showed up, delivered by Dr. Haffner himself, on the doorstep of Rhode Island optometrist Morton Silverman.18
Dr. Silverman “was instrumental in getting the Rhode Island legislation passed,” says Dr. Garston. The legislation he’s referring to is the country’s first DPA act in 1971. At the Airlie House conference, attendees toyed with the ideas of submitting 50 bills simultaneously, but the Ocean State wasn’t keen on waiting.17
|Optometric leaders flew in to the La Guardia airport, seen here in the 1970s, to meet at a nearby hotel. The meeting launched the profession’s efforts to aquire diagnostic drug privileges. |
“That La Guardia conference began the impetus for Rhode Island to become the first state to enact a DPA act in 1971. I like to think of the DPA bill in Rhode Island as ‘the Boston Tea Party,’” says Dr. Ferrucci.
Rhode Island established that optometrists could apply diagnostics as long as they had the educational credentials to do so. This opened up an opportunity for Dr. Garston. Because he had already developed a few years of experience with diagnostic drops and related instrumentation, they used him as a consultant. There was a provision in the law in Rhode Island, and every state copied this when they passed their bills.
“Since the ophthalmologists were saying we weren’t trained, we had to demonstrate that we could be trained and were being trained, so the training was given to every optometrist who wanted diagnostic and therapeutic capabilities,” Dr. Garston recalls. “So, I would go, for example, to Maine with other optometrists that I had trained, and presented local, hands-on courses on how to use the drugs. Once you dilate, there are more instruments you can use to examine the back of the eye. So, that’s what I did, along with others, in Maine, Rhode Island, Massachusetts and Pennsylvania. We physically trained the optometrists on how to use these agents to meet the provision in the law. This way, medicine could no longer claim we weren’t trained.”
This expansion not only changed what optometry was, but it changed what was printed between the covers of OJRO. Every issue throughout the ’70s featured news of the latest challenges and victories in DPA legislation. “While a growing number of states are considering the loosening of restrictions on the use of diagnostic drugs, the passage of the Oregon bill affecting some 340 optometrists boosts to four the number of states which already allow optometric use of such drugs,” reads a July 1975 issue.20
DPA passage was just one front in this era’s legislative battles. Congress passed a law establishing optometry services within the VA’s Department of Medicine and Surgery in 1976.9 “This was really a milestone,” says Dr. Ferrucci. “Optometrists were given vastly expanded clinical privileges. When optometrists in that system proved that they could perform competently advanced procedures, this became an impetus for the states to go to their legislatures and say, ‘the federal government allows optometrists in the military and in the VA to use all of these clinical privileges to the advantage of their patients, why can’t we?’”
While Dr. Garston and others were preparing ODs for DPA laws, a companion privilege, therapeutic pharmaceutical agent (TPA) laws, were coming into their own, too. At a January 1975 AOA Future Conference meeting in Tucson, Ariz., a team of optometric leaders pegged TPAs as their next target.18 And when the opportunity arouse, Drs. Dave Janney and John Casto won those victories. “These two rolled up their sleeves in 1976 to get the first optometric TPA bill enacted in West Virginia.”17
By the time dilation could be performed anywhere and TPA laws were steadily coming online, Review of Optometry was already asking—on its September 1989 cover—“Is optometry ready for laser surgery?”
A Shift Toward Comprehensive Care
By the mid-1970s, optometrists no longer identified with Charles Prentice’s cry “a lens is not a pill.” In a 1976 Review of Optometry article, Vincent Lupica, OD, wrote “the profession has undergone a considerable metamorphosis, emerging today as a provider of comprehensive eye care.”22
But it still didn’t have all the legislative tools it needed. For example, in 1981, just as David Cockrell, OD, was preparing to enter the field, he realized legislative restrictions might squash a dream he had studied years to obtain.
|This 1976 Review headline was a harbinger of the legislative changes that elevated optometry.|
“Around the time I was finishing school, I learned there were certain things I was being trained to do that I wasn’t able to do legally.” he says. “That’s when I learned, from some very astute leaders in Oklahoma optometry, that you have to get involved politically if you want to create legislative changes.”
In Oklahoma, where Dr. Cockrell practices, medicine came after optometrists for using laser treatments. “Oklahoma’s optometric statute stated that optometrists could treat ‘ocular abnormalities by any means.’ When laser procedures were introduced into eye care in the 1980s, ODs in Oklahoma were trained by the same people to do the same procedures at the same time as practicing ophthalmologists,” he argues.
Medicine challenged and, for a time, won. But, in 1997, Dr. Cockrell testified in support of legislation to reinstate Oklahoma optometrists’ laser privileges after those privileges were suspended the year before due to litigation initiated by ophthalmology.
After a series of successes in the first part of the century, optometric legislation faltered when, in the 1950s and ’60s, it wasn’t able to keep pace with optometric education. After a successful run of DPA and TPA laws throughout the ’70s, optometrists weren’t about to drop the ball again. “The momentum became unstoppable,” says Dr. Ferrucci. The pattern had been established. Legislators seemed amenable to the idea that if the training was available in optometry schools, it should be available in practice.
In 1982, the AOA established an ad hoc Long-Range Planning Committee. “This blue-ribbon committee met frequently over a two and a half year period and consisted of past AOA presidents and such optometric luminaries as Irvin Borish, OD, and Irving Bennett, OD. The committee was charged with the task of setting the direction of optometry for the foreseeable future,” says Dr. Ferrucci. “As a past president of AOSA, I was to represent the opinion of the younger generation of optometrists. As a member of the committee, I contributed to the wording of what became the new official definition of an optometrist. This landmark definition clearly established that optometrists were primary health care professionals with the ability to prevent, diagnose, treat and manage diseases and disorders of the visual system, the eye and its adnexa. It also made clear that optometrists had the knowledge to identify systemic disorders that had correlations to the eye and vision.”
|In 1990, the American Public Health Association supported ODs in their fight for therapeutic drug privleges, a huge boon. “Optometrists are located in most all communities; ophthalmic surgeons are more urbanly located,” explains Randall Thomas, OD. “Allowing any patient to be properly cared for without having to be referred to another doctor, is a win for patients.”|
One of those amenable legislators was US Senator Barbara Mikulski—then a congresswoman—who, in 1986, “was the spearhead for getting optometry included in Medicare,” says Dr. Ferrucci. Although some services, such as prescribing and fitting aphakic lenses, were available under Medicare since 1973, routine eye examinations remained prohibited, even though 95% of Americans who qualified had vision correction problems.23 “That was the impetus for us to really have the legitimacy if you will, to gain access to other managed healthcare plans. We owe her a lot.”
Here and there, optometrists showed they still exhibited the firebrand gene inherited from Charles Prentice. In 1989, Review of Optometry pondered aloud whether using civil disobedience was effective, retelling the tale of an Arizona doctor who, like Prentice, flouted the law and prescribed drugs to a patient who would otherwise have to drive 135 miles to an ophthalmologists.24 Tales of patient inconvenience were proving to be one of optometry’s most effective rhetorical tools. “Seventeen percent of our national panelists who treat are not licensed to do so,” the article reads. “There’s nothing wrong with refusing to abide by laws you feel are unjust, so long as you are willing to accept the consequences.”24
Passing Legislation: A Personal Matter
Dr. Cockrell attributes his state’s success on personal advocacy. “Legislation does not get passed on merit,” he says. “Legislation is passed when you personally educate your legislator on the clear need for legislation and how it will help the citizens. Building personal relationships with legislators provides the opportunity to educate them on the need for legislation and how it will benefit their constituents.” The broad development of these relationships allows for a “grassroots” strategy where all ODs who desire to pass the legislation can act together to achieve the goal.
Optometry honed those skills so finely that, in 1991, after Utah became the 26th state to adopt TPA legislation, Review of Optometry was running headlines like “O.D.s Expect New Wave of TPA Laws.” Legislation progressing the scope of practice was no longer something optometrists hoped for; it was becoming expected.
The aforementioned doctor who disobeyed Arizona law would no longer be in violation of the law by 1993 and, when TPA legislation passed in the last hold-out—Washington, DC—in 1998, no OD in the country would be.
An Eye on the Future: 1998-2016
For decades, optometry battled medicine. Ophthalmology groups, the American Medical Association and others sought to prevent ODs from practicing to the full extent of their education. But while optometry took every threat from these groups seriously, a different kind adversary was gaining strength and influence.
“In 1998, Pennsylvania passed its first TPA law. That allowed us to treat conditions such as bacterial infections. With the passage of legislation I now had the statutory authority to write a prescription and treat the patient, but I was not allowed to be a provider on the medical insurance panel. Therefore, I could not be reimbursed for my professional services,” says Greg Caldwell, OD, past president of the Pennsylvania Optometric Association. Even though Dr. Caldwell’s education and state legislature gave him the ability to prescribe, insurance companies were slow to follow suit. It was time for optometrists to organize again.
“I spent time making visits to these medical insurance payers, explaining to them what optometrists can diagnose and treat and, advocating for equal reimbursement for those services,” says Dr. Caldwell. “The payers would ask ‘why are you contacts-and-glasses guys here wanting to get reimbursed for treating glaucoma?’ Those questions allowed me to educate the payers that optometrists have the training and expertise to diagnose, manage and treat many ocular conditions including glaucoma.”
Again, every state had optometrists knocking on insurer’s doors, calling them. In Review, editorials and news articles speculated about how optometrists would get a fair shake. “When we talk about ‘access to patients,’ there are really two fronts: One, can we do it, through legislation in our optometric practice acts, and, two, through being a provider of the patient’s medical insurance,” he says.
Forefront of Change
Meanwhile, Oklahoma, Kentucky and Louisiana had all embraced a scope of practice approach that ended up affording them the broadest privileges in the country. The scope laws from these states are so broad because, rather than tacking on a new approval for each privilege, they simply defined what optometrists can’t do, Dr. Cockrell explains. These open-ended “exclusionary laws,” as they came to be known, got their inspiration from medicine, which is not bound by such descriptive statutes. “In 2005, we passed a law that literally excluded the things we couldn’t do—such as cataracts and retinal surgery—so that anything else that’s not excluded is automatically included.”
“One of the biggest challenges faced by optometry when passing legislation is that, frequently, medicine attempts to define our education to what we were taught in optometry school and ignore or downplay the quality of our continuing education system,” says Dr. Cockrell. “However, what the legislator may not realize is that MDs and ODs both must continue their education after they finish school.”
Now, when optometrists see health care legislation in the pipeline, they remember their long history fighting for recognition. Predicting they might be left out, they now preemptively make their voices heard. For instance, when Medicare launched physician quality reporting regulations (in 2007) and EHR Meaningful Use rules in 2009, Dr. Caldwell says, AOA members fought for optometry’s inclusion.
“A critical point is that medical doctors typically have a greater influence in the policy arena, due to their long-standing involvement,” he says. “We always say, ‘if you’re not at the table, you’re on the menu.’”
When President Obama’s sweeping health care reform bill, The Patient Protection and Affordable Care Act, was signed into law on March 23, 2010, optometrists were not fully included at the legislation’s inception. Through individual optometrists, as well as state and national associations, optometry was certain to get a say in the matter. The Harken Amendment (named after its champion, Sen. Tom Harkin) made sure health plans wouldn’t discriminate against optometrists. As usual, Review stood beside optometrists to help them navigate through the minutia of the 2,000-plus page law.25,26
Securing a Legacy
Optometry isn’t a profession for people easily satisfied. Its history is replete with mavericks, self-starters and independents. Every state and every era has had a Charles Prentice or a Norman Haffner or a Lou Catania or a Matt Garston who refused to be satisfied with the boundaries set before them. They inherited Albert Fitch’s restless drive. Dr. Fitch died in 1960, before any TPA or DPA laws came to pass and before 23 schools across America offered Doctor of Optometry degrees. But he would be proud to see the progress optometry has made, the battles won, to ensure ODs can treat serious eye diseases to the full extent of their education.
“The credit, at the end of the day, goes to organized optometry,” says Dr. Cockrell. “The coordinated efforts of the associations and individual optometrists move the profession forward. Legislative advances are never made by one or two people. Successful passage and implementation is only possible by organized optometry.”
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