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An Ophthalmologist's Definition of OphthaImology
Special Article
An Ophthalmologist's Definition of Ophthalmology BRUCE E. SPIVEY, MD
Abstract: Ophthalmology has long been on the vanguard of medicine and innovation. Ophthalmologists have enjoyed high levels of satisfaction from restoring sight to patients. But the world as we know it has shifted, and now we are burdened by the pressures of modern medicine and a competitive marketplace. Ophthalmology should take the lead in medicine in learning how to weather these crises and how to emerge a revitalized specialty. It seems that the right choice for the specialty of ophthalmology is to reclaim our role as comprehensive providers of total eye care. Ophthalmologists can lead teams formed to provide comprehensive eye care. A dialogue on a consensus definition of the scope of ophthalmology should take place, involving all segments of the profession. Another dialogue that is critical to the future of the specialty is a deliberate examination of the issue of formal accreditation and/or certification of ophthalmologic subspecialties. Ophthalmology needs to define itself for the future. Ophthalmology 1991; 98: 1877-1881
As the practice of medicine takes on more of a marketplace atmosphere, physicians of all kinds are coming under heavy external and internal environmental pressures: from practitioners outside the profession; from competitive forces within it; and from third party payers who never fail to read the bottom line on health care costs although they may not always read the full chart on health care quality-Snellen chart or otherwise. This discussion will not address the ills of all medicine, rather just some in ophthalmology. We can be proud that ophthalmology has long been on the vanguard of medicine and innovation. It needs now to be in the forefront of self-scrutiny and probably some midcourse self-correction. Ophthalmology needs to define itself for the future.
Originally received: August 26, 1991. Manuscript accepted: October 24, 1991. From the Department of Ophthalmology, California Pacific Medical Center, San Francisco. ' Presented as the 22nd Annual Jules Stein Lecture, Annual Postgraduate Seminar, Jules Stein Eye Institute, Los Angeles, March 1991. Reprint requests to Bruce E. Spivey, MD, Department of Ophthalmology, California Pacific Medical Center, 2340 Clay St, San Francisco, CA 94115.
Our calling, after all, was the first to define itself as a unique specialty.' Moreover, ophthalmology has long distinguished itself by creating and putting into practice diagnostic and therapeutic modalities as well as technological innovation, from the ophthalmoscope introduced 130 years ago to the excimer laser of the year 2000. Our residency programs draw the top 10% of medical school graduates. Compared with other specialties, ophthalmologists enjoy an exceptionally high level of emotional and intellectual satisfaction.' We experience the profound joy that comes from preserving or restoring sight and the stimulus of applying a nearly manageable, logical body of theory and knowledge to patients of all ages and states ofhealth, patients whose progress we can follow and oversee from testing through diagnosis to treatment and, in many cases, to cure. Our working conditions are generally pleasant, patient care hours tend to be shorter, and oncall shifts fewer. And financial compensation has been strong. Then what, if anything, is wrong? In a sense, none of our problems are unique to ophthalmology. Many other physicians are just as much criticized for estrangement from the public. Others are just as prone to the inexorable process of specialization within specialization and to fragmentation. Others also have been accused of paying heed 1877
OPHTHALMOLOGY
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to technology at the expense of humanity. Others also are in increasing competition with nonmedical practitioners. They are more and more divided by competition and advertising. All are under mounting pressure from private and public medical insurers to lower costs while improving, not merely maintaining, services. But, ophthalmologists-perhaps because we have been so successful for so long-have been the first to experience these pressures and have felt their impact with great intensity on our professional lives. We have felt the world shifting and changing as to how we are viewed as physicians. Managed care plans , third party payers, and gatekeepers are intervening between us and our patients; and often between us and our colleagues. That is why so many of us feel ourselves under siege, beset by a gnawing anxiety about the future. And that is why, it can be argued, we should take the lead for the various specialties of medicine in examining ourselves and in developing new approaches to our healing mission. Ophthalmologists have taken the lead so many times in our past. Could it be that ophthalmology can once again provide an example of how to weather these crises and stabilize and revitalize a specialty in seeming disarray? Without such timely, self-administered, preventive intervention, I fear we risk a steady degeneration of our professional position and our ability to provide the finest care to the community at large. Our first step should be to decide who we are.
DEFINING OPHTHALMOLOGY This may seem an odd challenge, but it is nonetheless an appropriate one. The fact is that we have a somewhat split personality. Ophthalmologists live in a house divided. Until about 40 years ago, all of us practiced comprehensive ophthalmology. You may ask, " What is comprehensive ophthalmology?" For some, it is still a fuzzy concept. I think that Dr. Bradley Straatsma's definition captures it best: "Comprehensive ophthalmology is a specialty devoted to giving high quality, cost-effective, efficient primary eye care in addition to the care, both medical and surgical, that does not require a categorical subspecialist.":' In the past, we performed ocular examinations far more often than we performed surgery. This is still true. In the past, patients looked to us for the capacity and the competence to provide the full range of eye care from the most basic to the most highly specialized. But, we cannot forget that times were once much simple. Just ponder the dramatic changes in the environment in which we practice medicine and in our ability to help our patients today. In 1924, for example , the American Academ y of Ophthalmology and Otolaryngology had a total of 1,426 members; that same year, 35 individuals were certified by the American Board of Ophthalmology. At that time, with very few exceptions, the practice of ophthalmology was all-inclusive. Our practices today, in most instances, still include the full range of patient care services that we trained for: from refraction and disease 1878
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NUMBER 12
screening through medical treatment, minor surgery, laser surgery, and intraocular surgery; but we do not describe ourselves in this way. Over the past few decades, there has been a trend toward subspecialization, particularly in the surgical arena. More and more since midcentury we have come to think of ourselves and introduce ourselves to others first of all as eye surgeons. We have taken on this identity even though, collectively, we spend only a fraction of our time-on average less than 10%4-performing surgery. In the course of this progressive transformation from generalist to specialist and subspecialist, ·ophthalmologists have gained much that is valuable ; at the same time, we have lost something else that is invaluable. Our biggest gains have been in science. We have acquired extraordinary technical know-how and skills to match our wonderful instrumentation. Our understanding of the disease process and its management has made tremendous strides on many fronts; strides that were not even dreamed of just a few decades ago. We have been trained to be the best and the most comprehensively skilled in eye care. However, in the process of becoming more and more specialized, we may have inadvertently sacrificed our commitment to resolving the fundamental problems of vision care for the American public. As the best-trained professionals and the only providers who can take care of total eye care needs, we have given the appearance of having relinquished our overall responsibilit y for every patient who comes into contact with the eye care delivery system. It is this evolution that requires us now to choose our identity. One choice is for ophthalmologists to declare themselves members of a specialty responsible only for treatment of surgical and complex medical eye problems. That is the direction in which, although not always consciously, we have been moving. The other choice is to proclaim ourselves the comprehensive providers of total eye care. That could be a hard choice for some; a challenge to reverse direction. Nonetheless, it appears to be the right choice for ophthalmology as a whole, recognizing that a significant percentage of us will continue as pure subspecialists. What we cannot afford to do, however, is fail to choose. The worst for us as a specialty would be that we choose neither option, and thus continue with a blurred self-image. This kind of inertia would place our future at risk.
WHY NOT SUBSPECIALIZE? I believe the future should embrace the tradition in which ophthalmology first prospered . We should reaffirm our role as leaders in the provision of comprehensive eye care. The University of California, Los Angeles, has already placed comprehensive ophthalmology in the academic mainstream. The alternative course, however, does have great attraction. It can be highly stimulating and gratifying to limit our practice to the special challenges of treating complex medical and surgical eye conditions. Increasingly,
SPIVEY
•
DEFINITION OF OPHTHALMOLOGY
technical innovation makes such work not only possible, but full of rewards, not the least of which are the excitement and aura associated with high technology . For the profession, however, there are grave drawbacks in letting this pattern become the defining one. Above all, it will further reduce the immediacy and availability of care for the public to the most qualified practitioner, and will bolster the already strong trend toward making ophthalmologists dependent on others for referrals and patients. If we relinquish our leadership in primary and comprehensive eye care, then those less trained and less capable will take up the slack. And, if we remove ourselves from the work of screening and treating medically simple eye problems, we must be aware of the consequences. Projections of disease prevalence and our own practice patterns indicate that the need for ophthalmologists could be reduced from over 13,000 practitioners now to between 3000 and 5000 in the future. Choosing the most restrictive definition of ourselves is a recipe for a shrinking profession; a specialty that would carry less weight in the field of medicine and have fewer resources to invest for technical innovation and scientific advances-ultimately to the detriment of the public. In my view, the public would not be well served by diminishing our numbers and ceding the field of primary care to others. Instead, we should be looking for a different concept for growth, a team approach to quality eye care. A team approach is a natural extension of ophthalmology's traditional leadership in eye care delivery. To be the leader, the ophthalmologist should direct and coordinate the efforts of different professionals in the best interests of the public.
A TEAM APPROACH As things stand now, there simply are not enough ophthalmologists to provide all the primary eye care that the public health requires . To meet the needs for general examinations, screening, and primary treatment, the United States would have to have thousands more ophthalmologists. I am not suggesting that we train more ophthalmologists just to insure that they, and not others , oversee delivery of such basic services. What I do suggest is that the supervisory and management role that ophthalmologists already provide , whether in the operating room or in the office, be extended into an eye care team. The public should rely on ophthalmologists as team leaders to carry out the fundamental medical responsibilities for definitive diagnosis, plus medical and surgical treatment of individual patients. Group practices are most obviously amenable to this type of practice , but solo practitioners and subspecialists can also benefit from this team approach. Under such an arrangement, ophthalmologists at man y practice sites across the country already guide nurses, technicians, optometrists, technologists , and others in the delivery of quality eye care. In partnerships and group
practices, in health maintenance organizations, and in academic health centers , such teams now fill the public's need for coordinated services. The most highly qualified individual , the ophthalmologist, directs the process of care from the beginning. As a physician, the ophthalmologist is best suited to determine the appropriate level of care for each patient. Patients profit most. In the hands of a full and wellcoordinated complement of professional ophthalmologistdirected eye care, patients benefit from the best of care, and , if we re-emphasize the human touch and nurturing, the best of caring .
DIALOGUE WITHIN THE PROFESSION A team approach to the provision of eye care,primary and comprehensive, as well as coordinated superspecialty care, therefore, seems to be the way of the future . Indeed , it looks like the future course that man y are already choosing. But this type of practice is only being consciously formed here and there. Would it not be better to have a genuine and far-reaching dialogue within the entire profession to help us decide who we are and what types of practices will fit the needs of the public in the future ? Such a discussion will not and should not prescribe a binding mandate for any individual ophthalmologist. Decisions that are reached should not be meant to rule out any ethical mode of practice, whether solo or large group practice. Ophthalmology has prospered because of the strong drive of each practitioner to be unique , to be an innovator. Diversity has been a key ingredient in our remarkable progress in the past, and it is a strength we must protect for the future . As the future already preoccupies so many of our informal talks, it is only sensible to see if we can tum our private conversations into genuine, specialty-wide dialogue. This dialogue should be broad-based, involving all the state and major subspecialty societies as well as individual ophthalmologists. It should be initiated by the American Academy of Ophthalmology, discussed and debated by the Council, and formalized through the Academy's Board of Directors. And the dialogue should establish a realistic, forward-thinking goal: a working consensus definition of the scope of ophthalmology that, in tum, will help to determine the profession's future educational needs and practice models. We need such an operating consensus for our own internal health and cohesion. And we need such unity of purpose so that the rest of medicine,our patients, the public, the government, and "third parties" understand and fully accept our role in eye care.
STATUS OF SUBSPECIALIZATION In the same vein, another critical dialogue that needs to take place concurrentl y is the examination of subspecialization within ophthalmology. We need to understand 1879
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how subspecialization has and will further change the practice of ophthalmology. We need to reach agreement as to what really are our subspecialties. For example, is cataract surgery really a subspecialty of ophthalmology? Or is it a special emphasis on a technique used in ophthalmic practice generally? Spiraling complexity of knowledge and advances in technology have led to an explosive growth of specialty and subspecialty fields of medicine. In the 1940s, only a handful of specialty areas were identified. By 1980, the number of formally recognized subspecialty certificates in medicine had grown to 30 (in addition to the basic 24 medical specialties) and by 1990 this had doubled again to 60 with 25 more actively progressing toward formal recognition today. None of these are in ophthalmology. This rush to subspecialize seems to fly in the face of managed care plans to discourage subspecialty referrals! We have, as a specialty, attempted to avoid formalizing the subspecialization that has evolved informally within our specialty. We have feared the effects of splintering along educational and socioeconomic lines, although the likelihood of such outcomes are discounted by some who are active in the fray of professionalizing subspecialties. It may very well be that we will decide to maintain our long-term, steady-as-you-go philosophy to forego subspecialty certification. But we need to maintain our course consciously and willfully, not by default or as a result of our own inertia. It may seem ironic that the precursor to the specialty movement, ophthalmology, is among the more reluctant to join the trend toward more formalized subspecialization. Our dialogue needs to be broad-based: it must include academia (the Association of University Professors of Ophthalmology), residency and fellowship programs, the American Board of Ophthalmology, major subspecialty societies, comprehensive ophthalmologists, and the American Academy of Ophthalmology. The intent of this dialogue is not to suggest or demand accreditation or subspecialty certification but to examine critically the issue of formal subspecialization. Each of us, in this and other specialties, must fully recognize that the diversity and growth of ophthalmology subspecialties has gone hand-in-hand with the remarkable modem advances in medical knowledge. But do we want to make it more formal? And if subspecialization is made more formal, how does this fit with primary and comprehensive care? Changes and movements that have occurred in the rest of medicine should be evaluated. They should cause us to pause and examine our present course to assure that it continues to be the best for our patients and ophthalmology.
EDUCATION FOR LEADERSHIP As we set out to examine ourselves and to exert greater control over our future, certainly we will find a clear need to make changes in our system of professional education. If we are to produce team leaders as well as technical 1880
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leaders, we may need to alter our approach to the selection and training of our future colleagues. Traditionally, we have based our selection process almost exclusively on academic performance, research activities, and conduct of direct clinical duties. We need to consider widening those criteria and our own sights to find and to train physicians with a broader outlook, to develop their leadership and managerial talents along with their technical mastery, and to hone their humane and ethical perceptions and instincts. We need, in other words, to commit our specialty to providing total care of the patient's vision, not just the performance of eye procedures; and we must develop educational systems that support such a commitment and that allow it to flourish . Otherwise we risk earning the technician's label that too many of our medical colleagues and patients are ready to pin on us. That is not the way we want the world to think of us or the way we want to think of ourselves.
ETHICS IN MEDICINE No discussion of this topic is complete without a comment on ethics. Ethics, of course, is integral to our identity as physicians, as ophthalmologists, and to the definition of ophthalmology. Adherence to ethical conduct should guide us in our professional calling. Without it, we begin to fall apart, split our profession, and shatter our public image and trust. Some will say that morality is inherent, not teachable as part of professional training. That issue has been debated for centuries and is not ours to resolve. Rather, we believe it is our obligation to make , at the very least, a concerted effort to explore , explain, and impart the very highest ethical standards in what should be lifetime medical education. The issue of ethics and humane conduct cannot be ducked as our profession defines itself. We cannot dismiss either the public's image of ophthalmology or our own anxiety or feelings of helplessness about these questions. We must hold ourselves accountable to these weighty responsibilities and perform to a higher standard.
CONCLUSION The description of these concerns about the profession of ophthalmology, its identity and its future , does not indicate a loss of confidence in our splendid specialty: 99.9% of the rest of the world would be ecstatic to face such challenges and to bring so many resources to the work ahead. As we define ourselves as team leaders and managers of all aspects ofeye care, we will need to bring other health professionals within the scope of our practice. We will need to acquire management skills. And we will need to diversify our image to embrace the reality of our being committed physicians, managers, refractionists, ocular
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internists, and family physicians, as well as ophthalmic surgeons. We have in our grasp the chance to lead not just eye care teams but medicine as a whole. We can set the example for all in medicine who already face or soon will face the challenges we are now moving to confront. Out of our own experience we can provide valuable guidance in ways to deal with the profusion of new technology and the new health care environment. The role of a leader is not easy. The risks of error, false starts, and failure are often high and always present . Having long been doers, action-oriented performers , ophthalmologists are well equipped to meet the hazards of leadership in medicine. We can put ourselves in the forefront of medical philosophy and medical practice, at the leading edge where history has placed us and where the future calls us. We should welcome the challenge and the chance it offers us to unite in a new consensus: about the nature of
our mission as ophthalmologists; about the identity of our calling as healers; and about the principles that direct our profession and ennoble our lives.
REFERENCES 1. Hirschberg J. Geschichte der Augenh eilkunde (2. Auf!. BD. 15) Hand buch der gesamten Augenh eilkunde ," Leipzig: Wilhelm Engleman , 1918. 2. Ow ens A. Ophthalmologists: the earnings edge gets smaller. Medical Economic s 1983; 60:85-93. 3. Straatsma B. In: The Impact of Subspecialty Fellowship Training on Residency Education , Proceedings of the AUPO Conference, Laguna Niguel, California, February 1988. Dallas: Assoc of University Professors of Ophthalmology, 1988; 83-4, Availible from: W. K. Kellogg Eye Center, 1000 Wall St, Ann Arbor, M148105 . 4. Mendenhall RC. Ophthalmology Practice Study Report: Final report , April 1979. Los Angeles : University of Southern California School of Medicine, 1979; 28-30.
1881
An Ophthalmologist's Definition of Ophthalmology BRUCE E. SPIVEY, MD
Abstract: Ophthalmology has long been on the vanguard of medicine and innovation. Ophthalmologists have enjoyed high levels of satisfaction from restoring sight to patients. But the world as we know it has shifted, and now we are burdened by the pressures of modern medicine and a competitive marketplace. Ophthalmology should take the lead in medicine in learning how to weather these crises and how to emerge a revitalized specialty. It seems that the right choice for the specialty of ophthalmology is to reclaim our role as comprehensive providers of total eye care. Ophthalmologists can lead teams formed to provide comprehensive eye care. A dialogue on a consensus definition of the scope of ophthalmology should take place, involving all segments of the profession. Another dialogue that is critical to the future of the specialty is a deliberate examination of the issue of formal accreditation and/or certification of ophthalmologic subspecialties. Ophthalmology needs to define itself for the future. Ophthalmology 1991; 98: 1877-1881
As the practice of medicine takes on more of a marketplace atmosphere, physicians of all kinds are coming under heavy external and internal environmental pressures: from practitioners outside the profession; from competitive forces within it; and from third party payers who never fail to read the bottom line on health care costs although they may not always read the full chart on health care quality-Snellen chart or otherwise. This discussion will not address the ills of all medicine, rather just some in ophthalmology. We can be proud that ophthalmology has long been on the vanguard of medicine and innovation. It needs now to be in the forefront of self-scrutiny and probably some midcourse self-correction. Ophthalmology needs to define itself for the future.
Originally received: August 26, 1991. Manuscript accepted: October 24, 1991. From the Department of Ophthalmology, California Pacific Medical Center, San Francisco. ' Presented as the 22nd Annual Jules Stein Lecture, Annual Postgraduate Seminar, Jules Stein Eye Institute, Los Angeles, March 1991. Reprint requests to Bruce E. Spivey, MD, Department of Ophthalmology, California Pacific Medical Center, 2340 Clay St, San Francisco, CA 94115.
Our calling, after all, was the first to define itself as a unique specialty.' Moreover, ophthalmology has long distinguished itself by creating and putting into practice diagnostic and therapeutic modalities as well as technological innovation, from the ophthalmoscope introduced 130 years ago to the excimer laser of the year 2000. Our residency programs draw the top 10% of medical school graduates. Compared with other specialties, ophthalmologists enjoy an exceptionally high level of emotional and intellectual satisfaction.' We experience the profound joy that comes from preserving or restoring sight and the stimulus of applying a nearly manageable, logical body of theory and knowledge to patients of all ages and states ofhealth, patients whose progress we can follow and oversee from testing through diagnosis to treatment and, in many cases, to cure. Our working conditions are generally pleasant, patient care hours tend to be shorter, and oncall shifts fewer. And financial compensation has been strong. Then what, if anything, is wrong? In a sense, none of our problems are unique to ophthalmology. Many other physicians are just as much criticized for estrangement from the public. Others are just as prone to the inexorable process of specialization within specialization and to fragmentation. Others also have been accused of paying heed 1877
OPHTHALMOLOGY
•
DECEMBER 1991
to technology at the expense of humanity. Others also are in increasing competition with nonmedical practitioners. They are more and more divided by competition and advertising. All are under mounting pressure from private and public medical insurers to lower costs while improving, not merely maintaining, services. But, ophthalmologists-perhaps because we have been so successful for so long-have been the first to experience these pressures and have felt their impact with great intensity on our professional lives. We have felt the world shifting and changing as to how we are viewed as physicians. Managed care plans , third party payers, and gatekeepers are intervening between us and our patients; and often between us and our colleagues. That is why so many of us feel ourselves under siege, beset by a gnawing anxiety about the future. And that is why, it can be argued, we should take the lead for the various specialties of medicine in examining ourselves and in developing new approaches to our healing mission. Ophthalmologists have taken the lead so many times in our past. Could it be that ophthalmology can once again provide an example of how to weather these crises and stabilize and revitalize a specialty in seeming disarray? Without such timely, self-administered, preventive intervention, I fear we risk a steady degeneration of our professional position and our ability to provide the finest care to the community at large. Our first step should be to decide who we are.
DEFINING OPHTHALMOLOGY This may seem an odd challenge, but it is nonetheless an appropriate one. The fact is that we have a somewhat split personality. Ophthalmologists live in a house divided. Until about 40 years ago, all of us practiced comprehensive ophthalmology. You may ask, " What is comprehensive ophthalmology?" For some, it is still a fuzzy concept. I think that Dr. Bradley Straatsma's definition captures it best: "Comprehensive ophthalmology is a specialty devoted to giving high quality, cost-effective, efficient primary eye care in addition to the care, both medical and surgical, that does not require a categorical subspecialist.":' In the past, we performed ocular examinations far more often than we performed surgery. This is still true. In the past, patients looked to us for the capacity and the competence to provide the full range of eye care from the most basic to the most highly specialized. But, we cannot forget that times were once much simple. Just ponder the dramatic changes in the environment in which we practice medicine and in our ability to help our patients today. In 1924, for example , the American Academ y of Ophthalmology and Otolaryngology had a total of 1,426 members; that same year, 35 individuals were certified by the American Board of Ophthalmology. At that time, with very few exceptions, the practice of ophthalmology was all-inclusive. Our practices today, in most instances, still include the full range of patient care services that we trained for: from refraction and disease 1878
•
VOLUME 98
•
NUMBER 12
screening through medical treatment, minor surgery, laser surgery, and intraocular surgery; but we do not describe ourselves in this way. Over the past few decades, there has been a trend toward subspecialization, particularly in the surgical arena. More and more since midcentury we have come to think of ourselves and introduce ourselves to others first of all as eye surgeons. We have taken on this identity even though, collectively, we spend only a fraction of our time-on average less than 10%4-performing surgery. In the course of this progressive transformation from generalist to specialist and subspecialist, ·ophthalmologists have gained much that is valuable ; at the same time, we have lost something else that is invaluable. Our biggest gains have been in science. We have acquired extraordinary technical know-how and skills to match our wonderful instrumentation. Our understanding of the disease process and its management has made tremendous strides on many fronts; strides that were not even dreamed of just a few decades ago. We have been trained to be the best and the most comprehensively skilled in eye care. However, in the process of becoming more and more specialized, we may have inadvertently sacrificed our commitment to resolving the fundamental problems of vision care for the American public. As the best-trained professionals and the only providers who can take care of total eye care needs, we have given the appearance of having relinquished our overall responsibilit y for every patient who comes into contact with the eye care delivery system. It is this evolution that requires us now to choose our identity. One choice is for ophthalmologists to declare themselves members of a specialty responsible only for treatment of surgical and complex medical eye problems. That is the direction in which, although not always consciously, we have been moving. The other choice is to proclaim ourselves the comprehensive providers of total eye care. That could be a hard choice for some; a challenge to reverse direction. Nonetheless, it appears to be the right choice for ophthalmology as a whole, recognizing that a significant percentage of us will continue as pure subspecialists. What we cannot afford to do, however, is fail to choose. The worst for us as a specialty would be that we choose neither option, and thus continue with a blurred self-image. This kind of inertia would place our future at risk.
WHY NOT SUBSPECIALIZE? I believe the future should embrace the tradition in which ophthalmology first prospered . We should reaffirm our role as leaders in the provision of comprehensive eye care. The University of California, Los Angeles, has already placed comprehensive ophthalmology in the academic mainstream. The alternative course, however, does have great attraction. It can be highly stimulating and gratifying to limit our practice to the special challenges of treating complex medical and surgical eye conditions. Increasingly,
SPIVEY
•
DEFINITION OF OPHTHALMOLOGY
technical innovation makes such work not only possible, but full of rewards, not the least of which are the excitement and aura associated with high technology . For the profession, however, there are grave drawbacks in letting this pattern become the defining one. Above all, it will further reduce the immediacy and availability of care for the public to the most qualified practitioner, and will bolster the already strong trend toward making ophthalmologists dependent on others for referrals and patients. If we relinquish our leadership in primary and comprehensive eye care, then those less trained and less capable will take up the slack. And, if we remove ourselves from the work of screening and treating medically simple eye problems, we must be aware of the consequences. Projections of disease prevalence and our own practice patterns indicate that the need for ophthalmologists could be reduced from over 13,000 practitioners now to between 3000 and 5000 in the future. Choosing the most restrictive definition of ourselves is a recipe for a shrinking profession; a specialty that would carry less weight in the field of medicine and have fewer resources to invest for technical innovation and scientific advances-ultimately to the detriment of the public. In my view, the public would not be well served by diminishing our numbers and ceding the field of primary care to others. Instead, we should be looking for a different concept for growth, a team approach to quality eye care. A team approach is a natural extension of ophthalmology's traditional leadership in eye care delivery. To be the leader, the ophthalmologist should direct and coordinate the efforts of different professionals in the best interests of the public.
A TEAM APPROACH As things stand now, there simply are not enough ophthalmologists to provide all the primary eye care that the public health requires . To meet the needs for general examinations, screening, and primary treatment, the United States would have to have thousands more ophthalmologists. I am not suggesting that we train more ophthalmologists just to insure that they, and not others , oversee delivery of such basic services. What I do suggest is that the supervisory and management role that ophthalmologists already provide , whether in the operating room or in the office, be extended into an eye care team. The public should rely on ophthalmologists as team leaders to carry out the fundamental medical responsibilities for definitive diagnosis, plus medical and surgical treatment of individual patients. Group practices are most obviously amenable to this type of practice , but solo practitioners and subspecialists can also benefit from this team approach. Under such an arrangement, ophthalmologists at man y practice sites across the country already guide nurses, technicians, optometrists, technologists , and others in the delivery of quality eye care. In partnerships and group
practices, in health maintenance organizations, and in academic health centers , such teams now fill the public's need for coordinated services. The most highly qualified individual , the ophthalmologist, directs the process of care from the beginning. As a physician, the ophthalmologist is best suited to determine the appropriate level of care for each patient. Patients profit most. In the hands of a full and wellcoordinated complement of professional ophthalmologistdirected eye care, patients benefit from the best of care, and , if we re-emphasize the human touch and nurturing, the best of caring .
DIALOGUE WITHIN THE PROFESSION A team approach to the provision of eye care,primary and comprehensive, as well as coordinated superspecialty care, therefore, seems to be the way of the future . Indeed , it looks like the future course that man y are already choosing. But this type of practice is only being consciously formed here and there. Would it not be better to have a genuine and far-reaching dialogue within the entire profession to help us decide who we are and what types of practices will fit the needs of the public in the future ? Such a discussion will not and should not prescribe a binding mandate for any individual ophthalmologist. Decisions that are reached should not be meant to rule out any ethical mode of practice, whether solo or large group practice. Ophthalmology has prospered because of the strong drive of each practitioner to be unique , to be an innovator. Diversity has been a key ingredient in our remarkable progress in the past, and it is a strength we must protect for the future . As the future already preoccupies so many of our informal talks, it is only sensible to see if we can tum our private conversations into genuine, specialty-wide dialogue. This dialogue should be broad-based, involving all the state and major subspecialty societies as well as individual ophthalmologists. It should be initiated by the American Academy of Ophthalmology, discussed and debated by the Council, and formalized through the Academy's Board of Directors. And the dialogue should establish a realistic, forward-thinking goal: a working consensus definition of the scope of ophthalmology that, in tum, will help to determine the profession's future educational needs and practice models. We need such an operating consensus for our own internal health and cohesion. And we need such unity of purpose so that the rest of medicine,our patients, the public, the government, and "third parties" understand and fully accept our role in eye care.
STATUS OF SUBSPECIALIZATION In the same vein, another critical dialogue that needs to take place concurrentl y is the examination of subspecialization within ophthalmology. We need to understand 1879
OPHTHALM OLOG Y
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how subspecialization has and will further change the practice of ophthalmology. We need to reach agreement as to what really are our subspecialties. For example, is cataract surgery really a subspecialty of ophthalmology? Or is it a special emphasis on a technique used in ophthalmic practice generally? Spiraling complexity of knowledge and advances in technology have led to an explosive growth of specialty and subspecialty fields of medicine. In the 1940s, only a handful of specialty areas were identified. By 1980, the number of formally recognized subspecialty certificates in medicine had grown to 30 (in addition to the basic 24 medical specialties) and by 1990 this had doubled again to 60 with 25 more actively progressing toward formal recognition today. None of these are in ophthalmology. This rush to subspecialize seems to fly in the face of managed care plans to discourage subspecialty referrals! We have, as a specialty, attempted to avoid formalizing the subspecialization that has evolved informally within our specialty. We have feared the effects of splintering along educational and socioeconomic lines, although the likelihood of such outcomes are discounted by some who are active in the fray of professionalizing subspecialties. It may very well be that we will decide to maintain our long-term, steady-as-you-go philosophy to forego subspecialty certification. But we need to maintain our course consciously and willfully, not by default or as a result of our own inertia. It may seem ironic that the precursor to the specialty movement, ophthalmology, is among the more reluctant to join the trend toward more formalized subspecialization. Our dialogue needs to be broad-based: it must include academia (the Association of University Professors of Ophthalmology), residency and fellowship programs, the American Board of Ophthalmology, major subspecialty societies, comprehensive ophthalmologists, and the American Academy of Ophthalmology. The intent of this dialogue is not to suggest or demand accreditation or subspecialty certification but to examine critically the issue of formal subspecialization. Each of us, in this and other specialties, must fully recognize that the diversity and growth of ophthalmology subspecialties has gone hand-in-hand with the remarkable modem advances in medical knowledge. But do we want to make it more formal? And if subspecialization is made more formal, how does this fit with primary and comprehensive care? Changes and movements that have occurred in the rest of medicine should be evaluated. They should cause us to pause and examine our present course to assure that it continues to be the best for our patients and ophthalmology.
EDUCATION FOR LEADERSHIP As we set out to examine ourselves and to exert greater control over our future, certainly we will find a clear need to make changes in our system of professional education. If we are to produce team leaders as well as technical 1880
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leaders, we may need to alter our approach to the selection and training of our future colleagues. Traditionally, we have based our selection process almost exclusively on academic performance, research activities, and conduct of direct clinical duties. We need to consider widening those criteria and our own sights to find and to train physicians with a broader outlook, to develop their leadership and managerial talents along with their technical mastery, and to hone their humane and ethical perceptions and instincts. We need, in other words, to commit our specialty to providing total care of the patient's vision, not just the performance of eye procedures; and we must develop educational systems that support such a commitment and that allow it to flourish . Otherwise we risk earning the technician's label that too many of our medical colleagues and patients are ready to pin on us. That is not the way we want the world to think of us or the way we want to think of ourselves.
ETHICS IN MEDICINE No discussion of this topic is complete without a comment on ethics. Ethics, of course, is integral to our identity as physicians, as ophthalmologists, and to the definition of ophthalmology. Adherence to ethical conduct should guide us in our professional calling. Without it, we begin to fall apart, split our profession, and shatter our public image and trust. Some will say that morality is inherent, not teachable as part of professional training. That issue has been debated for centuries and is not ours to resolve. Rather, we believe it is our obligation to make , at the very least, a concerted effort to explore , explain, and impart the very highest ethical standards in what should be lifetime medical education. The issue of ethics and humane conduct cannot be ducked as our profession defines itself. We cannot dismiss either the public's image of ophthalmology or our own anxiety or feelings of helplessness about these questions. We must hold ourselves accountable to these weighty responsibilities and perform to a higher standard.
CONCLUSION The description of these concerns about the profession of ophthalmology, its identity and its future , does not indicate a loss of confidence in our splendid specialty: 99.9% of the rest of the world would be ecstatic to face such challenges and to bring so many resources to the work ahead. As we define ourselves as team leaders and managers of all aspects ofeye care, we will need to bring other health professionals within the scope of our practice. We will need to acquire management skills. And we will need to diversify our image to embrace the reality of our being committed physicians, managers, refractionists, ocular
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internists, and family physicians, as well as ophthalmic surgeons. We have in our grasp the chance to lead not just eye care teams but medicine as a whole. We can set the example for all in medicine who already face or soon will face the challenges we are now moving to confront. Out of our own experience we can provide valuable guidance in ways to deal with the profusion of new technology and the new health care environment. The role of a leader is not easy. The risks of error, false starts, and failure are often high and always present . Having long been doers, action-oriented performers , ophthalmologists are well equipped to meet the hazards of leadership in medicine. We can put ourselves in the forefront of medical philosophy and medical practice, at the leading edge where history has placed us and where the future calls us. We should welcome the challenge and the chance it offers us to unite in a new consensus: about the nature of
our mission as ophthalmologists; about the identity of our calling as healers; and about the principles that direct our profession and ennoble our lives.
REFERENCES 1. Hirschberg J. Geschichte der Augenh eilkunde (2. Auf!. BD. 15) Hand buch der gesamten Augenh eilkunde ," Leipzig: Wilhelm Engleman , 1918. 2. Ow ens A. Ophthalmologists: the earnings edge gets smaller. Medical Economic s 1983; 60:85-93. 3. Straatsma B. In: The Impact of Subspecialty Fellowship Training on Residency Education , Proceedings of the AUPO Conference, Laguna Niguel, California, February 1988. Dallas: Assoc of University Professors of Ophthalmology, 1988; 83-4, Availible from: W. K. Kellogg Eye Center, 1000 Wall St, Ann Arbor, M148105 . 4. Mendenhall RC. Ophthalmology Practice Study Report: Final report , April 1979. Los Angeles : University of Southern California School of Medicine, 1979; 28-30.
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