Legislature(2003 - 2004)
02/03/2004 03:04 PM House HES
| Audio | Topic |
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
HB 306-OPTOMETRISTS' USE OF PHARMACEUTICALS
Number 1513
CHAIR WILSON announced that the final order of business would be
HOUSE BILL NO. 306, "An Act relating to the use of
pharmaceutical agents by optometrists." She commented that this
bill has been in the legislature in some version for many years.
Number 1589
REPRESENTATIVE RALPH SAMUELS, Alaska State Legislature, speaking
as sponsor of HB 306, told the committee that the bill would
allow optometrists to prescribe non-topical medications to treat
a patient's eyes or for an allergic shock reaction. There is a
list of dangerous drugs that optometrists would not be allowed
to prescribe. He shared that 40 other states and 85 percent of
the population in the United States are currently covered under
this type of system. There have been no reported problems over
the past 32 years, he added. All the western states currently
have this system in place. The only state [besides Alaska] West
of the Mississippi [River] that is not covered under this system
is Hawaii. The states that have not implemented this system are
states that have high-density populations where there are higher
numbers of ophthalmologists. Alaska has a unique problem with
such a huge land mass and so few doctors and little
accessibility to the health care system. In 1992 Alaska was the
32nd state to authorize prescriptions of therapeutic drugs to
treat eye diseases, and the compromise at the time was topicals
only, he said. He added that there have been no complaints to
the [Alaska Board of Examiners in Optometry] in the past 12
years [on optometrists' use of topical prescription drugs].
Number 1712
REPRESENTATIVE SAMUELS told the members that there would be
arguments about the differences in educational [background]
between optometrists and ophthalmologists. He pointed to the
chart in the members' packet which demonstrates the importance
of this legislation. For example, if an individual were to go
to a dentist to have a filling done, but first had to go to an
oral surgeon to administer the Novocain, it would not be good
public policy. He pointed out that dentists and optometrists
have exactly the same amount of education. Other examples he
noted were the ability of physician assistants [PAs] to
prescribe medications, and these individuals are not even
required to have an undergraduate degree; an advanced nurse
practitioner can also prescribe, and these individuals have two
years of postgraduate work. Representative Samuels noted that
podiatrists and dentists have the same four years of medical
school, and both of those doctors can prescribe. He summarized
that all physicians who have the same education are allowed to
prescribe medication, except optometrists.
REPRESENTATIVE SAMEULS told the members that this legislation
was passed [by] the [last] legislature with only two votes
against it, but it was vetoed by the then-Governor Knowles. The
previous legislature passed it though the House, but it did not
make it through the Senate. In areas of the state outside of
the road system the accessibility to good health care is
marginal at best, [and this legislation would help to address
that issue], he said.
Number 1874
MICHAEL BENNETT, O.D., testified in support of HB 306 and
answered questions from the members. He commented that
optometrists have been trained in prescribing oral medications
in [medical] school for about 20 years. He told the members
that optometrists see the vast majority of [eye care] patients
in Alaska. If there is a need for medical care that can be
dealt by using topical pharmaceuticals, then optometrists can
treat that. If the patient needs surgical care, then he/she is
referred to a surgeon. He explained that there is a small
minority of patients that require oral pharmaceuticals and there
are real inconveniences for those patients because there are
only a couple of choices in Juneau. One is to call an eye
surgeon but, of course, the patient would not be able to get in
that day, or a call could be made to his/her primary care
physician to see if the doctor would be willing to prescribe the
medication. He added this is awkward for the physician who is
not seeing the patient for the condition he/she is being asked
to prescribe treatment for and does not have the training to
make that judgment on his/her own.
Number 1958
DR. BENNETT told the members that the situation in rural Alaska
is much worse. Many communities in rural Alaska have
optometrists, but none have eye surgeons. He said his partner
for three years, who lives in Kotzebue, was the only eye care
practitioner in Northwest Alaska, and had to go to the physician
assistant to write the prescription. Aside from being awkward,
it is a needless delay for the patient, which is not good care,
he commented. If this treatment results in the patient's having
to do another office visit to a different practitioner, that
adds to the expense to the patient and delay in treatment. Dr.
Bennett said he feels strongly that this legislation will add to
better patient care.
DR. BENNETT offered a brief history on this issue and explained
that optometrists have prescribed topical treatments for over 12
years, and there has not been a single complaint brought to the
[Alaska Board of Examiners in Optometry] regarding prescription
of topical medications. When the topical prescription
legislation [came before the legislature] there were the same
scare scenarios then that are before the committee today about
oral prescription drugs. He noted that malpractice rates have
not changed in any states that have enacted this legislation.
These fees are extremely low, which he said speaks to the fact
that this is not a reckless profession that is trying to go
beyond its licensure and knowledge.
Number 2072
REPRESENTATIVE COGHILL asked Dr. Bennett to define some terms
that are in the bill [on page 1, lines 9 and 10] including:
ocular, adnexal, and anaphylaxis.
Number 2111
DR. BENNETT explained that ocular disease refers to the eye
itself. Adnexal disease refers to the tissues directly
surrounding the eye. Emergency anaphylaxis refers to a severe
hypersensitivity reaction to [something]. In response to
Representative Coghill's request for an example, Dr. Bennett
used the example of an individual who is allergic to bee stings.
If he/she knows of the condition in advance, it would be
advisable to carry an epinephrine injection, which [could be]
administers [in the case of an emergency]. Dr. Bennett pointed
out that currently a doctor of optometry is not allowed to do
that. He summarized by saying that optometrists can administer
topical treatments that could conceivably trigger an
anaphylactic reaction, but not treat [that reaction] if it
occurred in the doctor's office.
CHAIR WILSON pointed to [page 1], lines 5 where it says
"including a controlled substance, as defined in AS 11.71.900,"
and also language on [page 1], line 6 where it says "not a
schedule IA controlled substance". She asked Dr. Bennett to
explain this language.
DR. BENNETT responded that this language would allow for
optometrists to prescribe controlled substances other than those
that are illegal, such as heroin and the opiate-derived
controlled substances.
CHAIR WILSON asked what drugs an optometrist would be able to
prescribe.
DR. BENNETT responded that [optometrists would be able to
prescribe] any other drug that does not fall under [the IA
controlled substance] category.
Number 2193
REPRESENTATIVE GATTO posed a hypothetical example of an
individual who is stung in the eye by a bee. He is taken to Dr.
Bennett's office because it is believed there is something wrong
with the individual's eyes. Representative Gatto asked if Dr.
Bennett would be allowed to treat the emergency anaphylactic
[condition].
Number 2208
DR. BENNETT responded that he would not be able to treat that
patient. He added that it is unlikely that he would see someone
with a bee sting who is [experiencing an anaphylactic reaction],
and had only used that example as one that everyone would be
familiar with. It is more likely to be a situation in which a
patient has received a topically administered drop that would be
administered in the office that could cause an anaphylactic
reaction, he said. Dr. Bennett clarified his comments by saying
that optometrists are allowed to prescribe the drop, but not
allowed to treat an anaphylactic reaction.
REPRESENTATIVE GATTO commented that it is hard to believe
[optometrists] are not allowed to treat that.
Number 2224
REPRESENTATIVE CISSNA asked how often that happens and if anyone
has [died as a result of that].
DR. BENNETT responded that it has never happened to him;
however, he has one patient that he is aware of who has had an
anaphylactic reaction to common dilating agents. It occurred in
another office; she spent time in the hospital for it, and she
refuses politely to be dilated, he said. It is rare, but it
happens.
Number 2249
REPRESENTATIVE WOLF asked if oxycodone is a drug that would be
one that optometrists could prescribe [under this bill].
DR. BENNETT responded that it is a schedule IA controlled
substance [and not one an optometrists could prescribe].
REPRESENTATIVE COGHILL commented that one of the assertions he
has heard over and over again is that this legislation
jeopardizes eye safety in Alaska. He said he believes it is
important to determine what is good public policy.
Representative Coghill told the members that he has voted on
both sides of the issue and has asked for the Alaska State
Medical Board to come to the committee and [address this issue];
however, that has never happened. He noted that Dr. Carl
Rosen's letter says that the Alaska State Medical Board
unanimously opposes SB 78, which is a companion [bill] to HB
306. However, there may be some differences because SB 78 talks
about injections; however, that [language] is not in HB 306. He
asked if Dr. Bennett can provide some explanation to the Alaska
State Medical Board's opposition to this bill.
Number 2345
DR. BENNETT responded that he is not privy to the thoughts [of
the Alaska State Medical Board] and is not aware of how in-depth
the issue was reviewed. He told the members that he knows
primary care physicians who were surprised that [doctors of
optometry] do not already have these capabilities. He added
that while he cannot speak to the Alaska State Medical Board's
proceedings, it is important to note that there is the Alaska
Board of Examiners in Optometry. He noted that in most states
the optometry board does not involve itself in regulating
physicians, and said he cannot understand why the medical board
should have the authority to regulate optometry.
TAPE 04-7, SIDE B
Number 2344
REPRESENTATIVE COGHILL commented that as a legislator who is not
in the medical field, he is very uncomfortable getting into a
turf battle between one authority and another. He summarized
his understanding of the bill in that optometrists are asking
for prescription authority that is not dissimilar to a PA
[physician assistant], nurse practitioner, or dentist.
DR. BENNETT responded that the [prescription authority
optometrists are seeking] is most similar to a dentist's because
it is restricted to a specific area of expertise, as opposed to
the whole body. He pointed out that optometrists are not asking
to treat other medical conditions, only those involving the eye.
REPRESENTATIVE COGHILL asked, if an optometrist prescribed drugs
that are not used specifically for the eye, who the enforcing
authority would be in holding an optometrist accountable.
DR. BENNETT responded that the Alaska Board of Examiners in
Optometry would do that. It is a very conservative group, he
added. The procedure is the same as for physicians who stray.
There have been a few very highly publicized cases recently
where physicians have lost their license to practice by the
[medical] board.
Number 2282
REPRESENTATIVE COGHILL said that he is looking for good middle
ground where it is good public policy. He said when there is
one board saying one thing, and another board saying another, it
is tempting to make a law that combines the boards and then let
the board [make that determination]. This debate has been going
on for a long time. He said he is very concerned for eye
safety. And when someone claims that this bill will jeopardize
eye safety in Alaska, legislators take it seriously. He asked
Dr. Bennett if this bill will jeopardize eye safety for
Alaskans.
DR. BENNETT said it is pretty conclusive that [eye safety is not
jeopardized]. He commented that while not all of the 40 states
have [had this law in place] for a long time, there have not
been issues raised and none of those laws have been rescinded.
In the 50 states that allow topical prescriptions, none of those
laws have been rescinded. Dr. Bennett commented that he hopes
these facts speak to the lack of problems associated with this
type of legislation. He pointed out that malpractice rates have
not gone up, which would indicate that insurance companies have
not seen problems.
REPRESENTATIVE COGHILL noted that another assertion by those
opposing the bill is that [doctors of] optometry simply lack the
education and training necessary to appropriately prescribe
these drugs. He said that before he could vote in favor of this
bill, he would need to have [inrefutable] facts that that is not
true.
DR. BENNETT responded that 25 years ago when he was a graduate
student, he taught in the dental, optometry, and medical
schools. He told the members that all the anatomy courses were
the same, the pharmacology requirements and textbooks were the
same, and the number of course hours was similar. As far as
whole-body treatment, [optometry] is certainly equal to that of
the dental profession. Dr. Bennett explained that optometrists
have not been through residencies that deal with gall bladders,
lungs, and other organs, but neither have dentists. Dentists
have demonstrated that they have been very safe and effective
over a long period of time. He summarized his comments by
saying that optometrists are certainly as equally educated in
those areas as those in dentistry [who have the ability to
prescribe oral drugs].
REPRESENTATIVE COGHILL asked how the members are to compare this
education. He noted that a letter [dated January 29, 2004, from
Dr. Allan Jensen and Dr. Cynthia Bradford] to the committee
asserts that an ophthalmologist completes [eight years of
education and training], which is more significant than the
licensing requirements for an optometrist.
Number 2113
DR. BENNETT replied that he agrees with that, but pointed out
that optometrists are not asking to be ophthalmologists. He
added that this bill is not requesting surgical rights [for
optometrists]. He commented that a great deal of the training
and education [that ophthalmologists receive] is directed toward
surgical skills.
REPRESENTATIVE COGHILL said he would like to substantiate the
level of qualifications of optometrists. He said he would like
to know what part of this dispute is based on who gets the
market share or "the dollar bill," as opposed to what is good
health care in Alaska. He told the members that at this point
he is reluctant to move forward on the bill because he does not
have a clear understanding [of the issue]. He told the members
that he is surprised that as a schoolteacher he had to be
prepared to administer a shot for a diabetic student or for
someone who is allergic to bee stings, but an optometrist cannot
[administer the same thing].
Number 1996
SHERYL LENTFER, O.D., testified in support of HB 306 and
answered questions from the committee. She told the members
that access to the curriculums of the schools is readily
available. She urged the members to take a look at [the
curriculums] because she believes that will clarify the
education issue. She questioned why, if education is a big
issue, PAs and nurse practitioners are prescribing and not
prescribing with a doctor right behind them at every moment.
They are able to do this pretty much on their own, she
commented. Dr. Lentfer asked the members to deal with the
education issue factually by comparing [the curriculums] of the
optometry schools and medical schools. Dr. Lentfer stated that
education should not even be an issue in this debate. She urged
the committee to compare the education qualifications with those
for dentists or podiatrists.
DR. LENTFER told the members that she would like to talk about
who currently treats the public with oral prescriptions and the
educational relationship to these professionals. She said
medical doctors, osteopathic doctors, podiatrists, dentists,
nurse practitioners, and PAs all have prescriptive authority to
prescribe pharmaceutical agents in Alaska. Medical doctors,
osteopathic doctors, podiatrists, dentists, and optometrists all
have a four-year doctor degree.
DR. LENTFER clarified that after a four-year college
undergraduate degree, an optometrist receives a four-year
doctorate degree. There is no variation in that education, she
stated. Nurse practitioners have two years of master's work
after an undergraduate degree, but to her surprise she found
that PAs do not have to have a four-year undergraduate degree to
be accepted into the [PA] program.
Number 1916
DR. LENTFER emphasized that PAs and nurse practitioners have
been very beneficial to Alaska and that it is not her intention
to [undermine their role in ensuring good public health]. She
emphasized that her point is only to demonstrate the correlation
between their ability to prescribe drugs and their educational
background, compared to that of optometrists.
DR. LENTFER pointed out that the pharmacology education for
medical doctors, osteopathic doctors, and optometric doctors is
the same. She told the members that optometrists provide 70
percent of the eye care in the U.S. Considering that there are
many professionals treating eye conditions today including PAs,
nurse practitioners, physicians, and eye surgeons, that is a
large percentage. In Alaska [the percentage of eye care that is
provided by optometrists] is greater. There are 103
optometrists in 17 different locations, and many travel a lot.
There are only 28 eye surgeons in six locations, most of which
do surgery. She pointed out that with a population of over
500,000, eye surgeons availability and accessibility have been a
big challenge for this state. Dr. Lentfer explained that this
[fact] has put more demand on optometrists to practice to their
fullest training.
DR. LENTFER spoke to Representative Coghill's comments about
training. She told the members that this is not new or
additional training, since she was prescribing [oral
medications] in 1996 after graduating from medical school. She
told the members that while additional training is not required,
there will be additional training for those optometrist who have
not had prescriptive authority in the last few years. The
[Alaska Board of Examiners in Optometry] will require
optometrists to probably have over 200 hours of course work,
pass a test, and get a therapeutic endorsement on the license.
If the optometrist does not pass the test, he/she cannot
prescribe [oral medications], she said. An OD [doctor of
optometry] would have to have graduated [from medical school] in
the last two years in order to be qualified to prescribe. When
therapeutic eye drops were approved by the legislature,
optometrists were not automatically allowed to prescribe because
the [Alaska Board of Examiners in Optometry] required that
optometrists prove that they were qualified.
DR. LENTFER pointed out that the language in this legislation is
for the treatment of eye-related conditions, as the language on
line 9 and 10 is very specific where it says "ocular disease or
conditions, ocular adnexal disease or conditions, or emergency
anaphylaxis." She added that [this language] makes it clear
that optometrist are not interested in prescribing a broad
spectrums of pharmaceuticals like PAs or nurse practitioners.
The only interest in prescribing is for the treatment of
conditions and diseases for which optometrists are trained and
practicing.
DR. LENTFER explained that it is difficult physically, as well
as financially for patients to be sent from an optometrist's
office to another practitioner's office to receive treatment
that the optometrist has prescribed. In some instances this
requires the patient to travel some distance, she said. Dr.
Lentfer told the members of an individual who needed an oral
prescription for a drug that would relieve a condition she had
diagnosed, but could not find a practitioner to prescribe the
medication. In this case the medication is most effective when
administered within the first 48 hours.
Number 1719
DR. LENTFER told the members that after the then Governor
Knowles vetoed the legislation that passed the Alaska House of
Representatives and the Alaska State Senate, the Alaska Board of
Examiners in Optometry went to the State Medical Board and did
everything Governor Knowles requested. She stated that there
was no cohesiveness. The "so-called turf war" is not a good
reason to make a judgment on this bill. The only reason to
support this bill is to provide better health care for Alaskans.
Number 1680
CHAIR WILSON explained that she worked in the clinic Tok where
she worked with a PA or a nurse practitioner who were under the
umbrella of a [physician]. She asked if optometrist would want
work under [the umbrella] of a physician in the prescribing of
drugs.
DR. LENTFER responded that optometrists have already completed a
four-year doctorate degree program. She said the same
comparison could be made in asking a dentist to work under a
medical doctor.
CHAIR WILSON clarified that she is not talking about dentists;
she is talking about PAs and advanced nurse practitioners.
DR. LENTFER responded that going under an umbrella of another
physician does not make sense. Whose umbrella would
optometrists be under? She said that optometrists are
established entities with a regulating board that has an
excellent history. If the committee had doubts about
optometrists' education, training, and ability to prescribe
[oral] medications, she urged them to research the educational
background. Optometrists are not [in the same educational
category] as PAs or nurse practitioners. The educational
background is the same as for dentists and medical doctors in
pharmacological education. Dr. Lentfer asked why optometrists'
educational qualifications are in question, when those for
dentists and medical doctors are not.
Number 1587
CHAIR WILSON responded that the [educational qualification] is
in question because optometrist have not had the other
specialized training. Professionals who have not had that
training [such as PAs and nurse practitioners have had to] work
under other professionals.
DR. LENTFER told the members that she took human anatomy,
neuroanatomy, physiology, pathology, ocular biology, and ocular
physiology at the same time. She explained that, depending on
which medical school a medical student goes to, in the third or
fourth year there is a series of rotations. During this time
the medical student is trying to decide what kind of doctor
he/she chooses to be. For those [students] that know they want
to be an eye doctor, in the third year of medical school they
begin to see patients. She explained that at the school she
attended, the first-year ophthalmology residents were under
[fourth-year optometry students] in emergency care. Dr. Lentfer
emphasized that optometry students not only learn about the
whole body, but also specialize in eye care, while other medical
students are learning about the whole body and not specializing.
The fourth year of medical school consists entirely of clinical
hours. There are as many as 2,000 patient hours before
finishing the fourth year of medical school, which is very good
for any health care profession.
Number 1523
REPRESENTATIVE GATTO pointed out that paramedics in Anchorage,
after only a year of sporadic training, give intracardiac drugs
during ventricular fibrillation. It is not only allowed, it is
essential. He pointed out that there is a precedent for other
groups to do what the optometrists are asking to do.
Representative Gatto said with that in mind, he'd looked at Dr.
Carl Rosen's letter, and asked Dr. Lentfer to comment on a
couple of statements in that letter. One statement is that HB
306 jeopardizes patient eye safety. The second statement is
that optometrists do not have clinical experience to safely
administer eye injections. The third statement is that [an
expanded scope of practice for] optometrists still would
endanger patients.
DR. LENTFER responded [to the second statement by saying] that
nothing in this bill talks about eye injections. Optometrists
do not want to do eye injections, she stated.
CHAIR WILSON interjected that there may be confusion about that
issue because the sponsor's statement refers to oral or
injectable medications.
Number 1439
DR. LENTFER emphasized that optometrists are not interested in
[injectable medications] because that is an invasive procedure
which should be done by a surgeon.
Number 1381
DR. LENTFER responded to the [third statement that an expanded
scope of practice for optometrists would still endanger
patients] by saying that she would like to hear how Dr. Rosen
[would justify that statement]. She said, for example, before
optometrists had authorization to use topicals, if she had
someone in a chair in her office who had very high pressure in
the eye, that person could go blind immediately because [she
could not treat that condition]. Dr. Lentfer summarized that
this was the same kind of statement being made before
authorization was given to prescribe topical treatment. She
pointed to the problems associated with finding a physician to
prescribe an oral medication to treat conditions and said if
contact for prescribing the medication is an hour or two later,
the patient will lose sight. That is the danger, she stated.
REPRESENTATIVE COGHILL commented that some of the backup
material referred to the extended use of steroids and how that
might affect the eye or the rest of the body. That was cited as
one of the first dangers in allowing this bill to go through.
He asked Dr. Lentfer to respond to that statement.
DR. LENTFER responded that steroids would not be used. One
exception] might be if in a rural area; however they would only
be prescribed in conjunction with a physician or
ophthalmologist. She told the members that often she will see
patients who have been prescribed oral steroids from the
physician and the eye pressure is elevated. She pointed out
that often physicians will forget to tell patients who are on
steroids to get their eye pressure checked. Steroid treatment
is something that would always be administered with [the
consultation of] another physician, she commented.
REPRESENTATIVE COGHILL asked if that is a professional barrier
that would always be present. He commented that there is the
charge is that this could be a significant problem.
DR. LENTFER replied that is a serious drug and when it comes
time to cross that bridge, optometrists will either be referring
the patient to another doctor or calling another doctor. The
drugs that optometrists would use are antibiotics, antivirals,
or maybe some low-dose pain medications. Pain medication might
be prescribed if, for instance, a foreign body was removed from
the eye and it was really needed, she said.
Number 1185
REPRESENTATIVE COGHILL noted that there is reference to the
problem of over-prescribing of antibiotics. He asked Dr.
Lentfer to comment on that.
DR. LENTFER responded that she believes those concerns regarding
[over-prescribing antibiotics] belong with every single health
care professional. What this comes down to is the professional
judgment of doctors of optometry. There are many things that
optometrists do [annually] to stay informed, including reading
medical journals and 48 hours of continuing education.
Licensing hinges on whether these requirements have been met,
she said.
REPRESENTATIVE COGHILL asked Dr. Lentfer to help him understand
the idea of systemic drugs and their impact on the whole body.
DR. LENTFER responded that whenever prescribing oral
medications, it is important to be aware of the side effects,
drug interactions with other prescriptions the patient might
take, and the general health of the patient. It would be
important, for example, to be aware of any liver or kidney
diseases. If it is determined that a patient has a systemic
condition, the optometrist would refer the patient to his/her
medical doctor.
REPRESENTATIVE COGHILL asked Dr. Lentfer to help him understand
the interaction of drugs, particularly with seniors who often
have conditions that require multiple prescriptions.
DR. LANTFER responded that in medical school the pharmacology
program covers the entire mechanism action of every drug,
including classification of drugs, offshoots, side effects,
contra-indication, and what drugs cannot be taken [together].
She told the members that every exam form that patients complete
lists the drugs that the patient is taking and why the patient
is taking it. So all of that is taken into consideration before
any prescription is written, she said. Dr. Lantfer emphasized
that the education of optometrists is the same as for general
physicians.
Number 0889
CHAIR WILSON said she hears Dr. Lantfer saying over and over
again that optometrists have the same training as a medical
doctor, but she said she knows that medical doctors study
different systems. She said she believes that medical doctors
go into greater depth on how everything interconnects, and that
is what is causing her [to be reluctant in supporting the bill].
Number 0718
DR. LENTFER asked Chair Wilson if she has been able to compare
[the educational training between optometrists and medical
doctors].
CHAIR WILSON responded that she has talked with people on this
issue, but has not researched it personally.
DR. LENTFER asked if Chair Wilson's sources told her where
medical doctors get this extra [in-depth training].
CHAIR WILSON said she is not concerned with where [medical
doctors] get the extra training, but that they have it.
DR. LENTFER agreed that if a doctor plans to be a specialist,
such as a surgeon, he/she does receive extra training. She
pointed out that optometrists do not do surgery. Optometrists
are only asking for primary care, which is what is studied in
medical school, she added. She emphasized that the same
classes, textbooks, and disease and treatment issues are covered
in medical schools for optometrist as for [a general physician].
Number 0645
CYNTHIA BRADFORD, M.D., Secretary for State Affairs, American
Academy of Ophthalmology, testified in opposition to HB 306.
She told the members that she represents the American Academy of
Ophthalmology's 26,000 members. Dr. Bradford said that while
the bill is short, it has dramatic ramifications for health care
in Alaska. She highlighted her educational background to give
the committee a perspective on her comments. She told the
members that she is a physician, ophthalmologist, and professor
of ophthalmology at the University of Oklahoma. She said she
has been active throughout her career to give medical school
graduates the skills necessary to become qualified specialists
in eye care.
Number 0490
DR. BRADFORD told the members that she supports Dr. Rosen's
views expressed in his letter to the committee [dated May 8,
2003], and the American Academy of Ophthalmology supports his
concerns. Expanding [optometrists'] authority to prescribe
drugs is a serious public health issue, she said. She went on
to say that while on the surface it may appear appropriate for
[optometrists] to prescribe oral drugs, closer scrutiny reveals
significant quality care and patient safety issues which need to
be considered. Dr. Bradford said it is impossible to divorce
the eye and visual system from the rest of the body because it
is a part of the body. Many diseases in other systems of the
body manifest themselves in the eye. Appropriate diagnosis
requires many years of professional training in accredited
programs. She said that would include three years beyond
medical school and an internship for ophthalmology.
DR. BRADFORD clarified that the eye is not a tooth and is one of
the most complex and delicate body parts. Optometrists do not
have the comparable education and training or experience to use
the broad range of drugs that HB 306 would authorize, she said.
She talked about various medications and the abuse of those
substances.
Number 0310
DR. BRADFORD told the members of the complications of
inappropriately prescribing antibiotics and controlled
substances. She explained that during her internship she
received vast experience in prescribing controlled substances.
It is very rare to prescribe a narcotic for an eye condition,
she said. When it is used, it is normally after eye surgery.
Dr. Bradford cautioned that seniors who have serious eye
conditions often have [other] chronic illnesses and are often
less tolerant to a drug's side effects. In these cases, careful
evaluation and close coordination by an ophthalmologist is
essential, she stated.
Number 0261
DR. BRADFORD told the members that four years of medical school
does not equate to eight years of ophthalmology training and
education. She said that not only do optometrist not possess a
medical degree, they are not required to complete clinical
rounds, internships, and residency that focus on patients with
serious eye disease. In contrast to optometry training,
ophthalmologists complete four years of medical school, a one-
year hospital residency, and a three-year ophthalmology
residency. She asked the members to oppose HB 306.
REPRESENTATIVE COGHILL asked Dr. Bradford to draw a comparison
between the optometrist's and ophthalmologist's training in
pharmacology. He noted that often when ophthalmologists are in
residency, much time is dedicated to surgery.
DR. BRADFORD agreed that there is a pharmacology course where
the basics in medication are covered. It is important to
understand the disease process, which is covered in pathology,
and physiology teaches how the body parts work, what can go
wrong, and how the drugs interact there. Those are the basic
background courses, Dr. Bradford explained. During the clinical
years the [medical students] begin to apply the paperwork and
see firsthand not only the downside to every medication, but
also the justifiable need for the medication. There are two
years during which these students have a physician looking over
their shoulder and telling them that they cannot use a
particular drug, she said. Through that process, the student
learns what he/she should or should not be prescribing.
TAPE 04-08, SIDE A
Number 0027
DR. BRADFORD pointed out that the internship is a difficult year
that is an important decision-making and learning process. The
internship is followed by the ophthalmology residency [after
which] the resident knows how to manage the general medical
care. The intern then relates the eye diseases back to the
medicine. Dr. Bradford related that due to her background in
medical school, she can look at a patient and know diseases the
patient doesn't know he or she has. Optometry school does not
provide that experience.
REPRESENTATIVE COGHILL surmised that there are bases in training
that are similar, and as a policymaker, he explained that he's
trying to determine where the specialty comes into play. The
committee, in reviewing this legislation, must determine whether
the expansion in this legislation can be tolerated or not.
Representative Coghill related his understanding, then, that
during the internship the intern is allowed to prescribe drugs
with serious oversight.
DR. BRADFORD clarified that the oversight occurs during medical
school; the internship has much less oversight. Interns write
medical prescriptions, the nurses fill those prescriptions, and
the pharmacists dispense the intravenous (IV) medication.
REPRESENTATIVE COGHILL remarked that the internship occurs
fairly early in the formative years of the doctor. He inquired
as to the difference of [that experience] versus that of the
optometrist with the same level of training.
DR. BRADFORD stated that the optometrist hasn't had the same
level of training because the optometrist hasn't been through
two years of medical school with close oversight. Furthermore,
ophthalmologists don't often see a patient who only has the
problem of needing glasses, which is often the case for
optometrists. Most of the patients seen by ophthalmologists
have some sort of eye disease, and therefore these
ophthalmologists see a variety of different eye diseases.
Therefore, an optometrist would not have the same experience as
an ophthalmologist with regard to seeing ocular disease.
Number 0329
REPRESENTATIVE COGHILL remarked that it seems that what is being
[proposed in this legislation] is minimal prescriptive
authority. He said from those describing the legislation, he
has ascertained that the drugs [the optometrists would be
allowed to prescribe] are on the lower end of the
pharmacological ladder.
DR. BRADFORD pointed out that when one is prescribing narcotics,
one must take care not to miss the diagnosis. She expressed
concern with [optometrists'] being allowed to prescribe
narcotics to kill pain when it's rare that such is necessary for
eye conditions. She expressed further concern that [pain
medication] could mask the symptoms of true eye disease.
REPRESENTATIVE COGHILL clarified that he is looking at the
principle of operation without going into the anecdotal side
because one could probably find "bad people" on both sides. He
specified that he is trying to determine what's the best
medicine and practice.
DR. BRADFORD said she agreed, but noted that in eye care she
doesn't write many narcotic prescriptions - perhaps one or two a
year. In general eye care, [narcotic prescriptions] aren't
necessary. Most narcotic prescriptions for eye care are given
after surgery.
Number 0493
REPRESENTATIVE COGHILL inquired as to the professional peer
review discussion between ophthalmology and optometry that could
be reviewed to determine the professional barriers in education
and practice in order to help the legislature understand how to
license the profession.
DR. BRADFORD explained that [ophthalmologists] generally say
they look at eye diseases and want to treat patients to a
certain level. The American Board of Ophthalmology has assigned
the educational requirements to do what ophthalmologists do.
She explained that the American Board of Ophthalmology looks at
different disease processes and make an assessment with regard
to what is necessary to train someone to understand and treat
eye diseases. Ophthalmologists are tested to ensure that they
reach this level. Furthermore, [the American Board of
Ophthalmology] determines how much patient experience is
necessary in order to be good. She predicted that as the world
becomes more complex, if anything, more time would be added.
There has never been a time when [ophthalmologists] have said
they, as a profession, should cut back and not train as much.
CHAIR WILSON recalled earlier testimony that optometrists had
the same training and actually trained students who are studying
to become ophthalmologists.
DR. BRADFORD responded that it isn't common, and noted that
there is a great deal of variability with regard to optometry
school training.
Number 0706
MICHAEL LEVITT, Staff, American Academy of Ophthalmology,
returned to the earlier discussion surrounding oxycodone and
what schedule drug it is. He informed the committee that a drug
intelligence brief from the U.S. Drug Enforcement Agency
specifies that oxycodone is a schedule II drug under the
Controlled Substances Act because of its high propensity to
cause dependence and abuse.
Number 0762
CARL ROSEN, President, Alaska Academy of Ophthalmology, informed
the committee that he is an ophthalmologist practicing at
Ophthalmologic Associates, which is the largest eye practice in
Alaska. He also informed the committee that he has taken care
of Alaskans, performing orbital reconstruction, eyelid plastics,
and neuro-ophthalmology for the past 10 years. He noted that he
practices with six ophthalmologists and two optometrists. Dr.
Rosen said that he believes there has been a lot of misleading
discussion, especially since it's difficult for nonphysicians to
understand the vernacular of the [eye care] community and how it
works.
DR. ROSEN recognized that this legislation isn't new, as there
have been multiple versions over the past four years; the most
recent legislation was an attempt at "hijacking" SB 270 in 2002.
However, SB 270 failed as Democrats and Republicans joined
together to take the optometric scope out of the legislation.
Dr. Rosen emphasized that [optometrists and ophthalmologists]
don't receive the same training. He also emphasized that there
is a vast difference between the requirements, the population
that takes the tests, and the curves on which one is graded.
Dr. Rosen related that he spent at least 24,000 hours of
clinical training; one year of medical internship; three years
of residency; and a year of fellowship training. He explained
that he dealt with sick patients in a cardiac care unit in which
he dealt with oncology and neurology. However, Dr. Rosen said
that once medical school is complete, one really learns the
craft. For further clarification, Dr. Rosen highlighted that
the American Academy of Ophthalmology requires board
certification, while the American Academy of Optometry does not.
Furthermore, there is recertification in the American Academy of
Ophthalmology, which he noted he is currently experiencing.
During this recertification, medical ethics courses, 300 hours
of continuing medical education, chart reviews, and an exam [are
required].
DR. ROSEN related that in his opinion and that of the American
Academy of Ophthalmology, this legislation is dangerous for
patients. This legislation would allow the Alaska Board of
Examiners in Optometry, not the [State] Medical Board, to
oversee its members, with which he disagreed. He related that
[the American Academy of Ophthalmology] believes in legislating
medical knowledge and skills that will affect the quality of
patient care. Dr. Rosen concluded by saying, "Leave the
practice of medicine to medical school graduates."
Number 1054
REPRESENTATIVE COGHILL inquired as to why Dr. Rosen doesn't
believe the Alaska Board of Examiners in Optometry has the
ability to handle the cases that might come before it.
DR. ROSEN pointed out that the optometric board can't come to a
consensus with regard to testing its own constituents, and
therefore there is no national certification. Furthermore, he
believes something is wrong if the optometric community says
that there have been no complications with anything they've done
over the past 12 years because everyone has a complication. The
problem is with regard to tracking reported problems because
there is no database on such. However, the complicated patient
ultimately ends up in [an ophthalmologist's office], where the
patient complains.
REPRESENTATIVE COGHILL suggested that HB 306 be held. He then
turned to his earlier question regarding the peer review in the
medical arena with regard to the education level and the
practice ability.
DR. ROSEN related his belief [that this matter has come about]
because [the optometrists] have trained and now want to do more.
However, the medical community doesn't recognize that want. He
stressed the need for there to be appropriate medical training
that is recognized by the medical community. If the
aforementioned can be offered, then the medical community would
[become involved] and some sort of consensus could be developed.
However, the aforementioned hasn't occurred. Furthermore, when
there have been discussions, a year later there is something
that needs to be added in order to satisfy the patients'
requirements and needs.
CHAIR WILSON noted that she has spoken with both sides of this
issue. One side says that [what HB 306 proposes] is how it's
done in almost all the other states, while the other side says
that only four states do this. Therefore, she requested an
answer to the foregoing by the next hearing on this legislation.
Chair Wilson encouraged the [optometrists and ophthalmologists]
to come together to work this out. She expressed concern with
regard to the optometrists' policing themselves. [HB 306 was
held over.]
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