An Open Letter to Governor Jay Inslee
Veto SSB 5389
Dear Governor Inslee:
I am writing to you as President of the Washington Academy of Eye Physicians and Surgeons (WAEPS) to urge you to VETO SSB 5389. The Academy represents the vast majority of Washington ophthalmologists who have strongly opposed optometric scope expansion since the bill was originally proposed and we would welcome the opportunity to discuss this legislation with you in person.
As part of a Department of Health Sunrise Review for scope expansions, three issues are typically reviewed -- access, cost, and safety. In its review of the optometrists’ proposal, the DOH found that there is no evidence of an access problem, that cost is not a barrier to ophthalmic care, but that the proposal from the optometrists raises specific patient safety issues regarding certain surgical procedures. Below, WAEPS will primarily focus on the last issue.
If enacted, SSB 5389 would create a new class of surgeon in Washington. All Washington surgeons currently have hands-on live patient surgical training on hundreds of patients over thousands of hours before they graduate and enter practice. MDs, DOs, podiatrists, dentists, and others have nationally mandated minimum surgical training requirements. Because optometrists’ scope of practice is determined at the state level and their schools are located in 23 different states, they have no such hands-on live patient surgical training standards and there are only limited surgical training requirements mandated in SSB 5389.
The differences in training between optometrists and ophthalmologists are dramatic. After undergraduate studies, optometrists attend a 4-year doctoral program and receive the degree of OD (optometric doctor). This non-surgical education includes roughly 2,000 supervised clinical hours with direct patient contact during their final year of school. However, of the 23 optometry schools in the US, only 3 are in states where any hands-on, live patient training is permitted (OK, KY, and TN). That is due to scope of practice laws permitting some limited surgery in only those three states. That means that nationally nearly 90% of graduating optometrists receive no hands-on surgical training during their doctoral program. They only receive lecture and lab-style instruction including training on model eyes and other inanimate objects.
Ophthalmologists, on the other hand, are MDs or DOs. After undergraduate studies, ophthalmologists attend 4 years of medical school. During medical school, they receive extensive surgical experience on live patients after which they all must do a medical/surgical internship followed by 3 more years of ophthalmology residency training before being able practice. This experience represents 15,000 or more hours of clinical training.
We know that you understand the complexities of eye surgery and we hope that you agree that eye surgery should only be performed by medically and surgically trained ophthalmologists who have completed this extensive training.
As introduced, SB 5389 proposed that optometrists be permitted, among other things, to perform a range of laser surgeries. The Department of Health recommended that the Legislature not grant them laser authority, and the Senate ultimately amended its bill to follow that recommendation, while making no changes to other aspects of the legislation.
The House focused on different parts of the DOH recommendations as well as the possibility of aligning Washington law with that of our neighboring state, Oregon. That state specifically prohibits optometrists from doing invasive procedures, or using sutures, and allows only certain injections. (Throughout session, optometrists and some southwest Washington legislators argued Oregon and Washington optometrists should have the same scope of practice.) As the House considered appropriate amendments, WAEPS endeavored to educate House members on how to align the bill with Oregon. However, the bill as passed the House does NOT reflect Oregon’s more restrictive law.
Contrary to the limitations in Oregon, if signed into law SSB 5389 authorizes optometrists to perform seven new “advanced procedures”, some of which are significant surgeries that even comprehensive ophthalmologists typically refer to oculofacial plastic surgeons.
1. Perform “eyelid surgery” with some limitations.
2. Perform incision and excision of chalazia.
3. Perform excisions of the conjunctiva on the surface of the eye
4. Perform injections on and around the eye as well as the eyelids.
5. Performing paracentesis (using a needle to remove fluid from the eye)
6. Prescribe systemic steroids both orally and by injection/infusion.
7. Perform light therapy of the skin around the eye.
8. Perform tear duct probings on infants and adults.
One key recommendation of the DOH’s Sunrise Review, supported by WAEPS, was collaboration in the rule-making process between the Washington Medical Commission and the Board of Optometry. This was important because current members of the BOO have not had the opportunity to receive hands-on surgical training on living patients but will have to write rules on that as well as other training requirements. An amendment to include the WMC was passed by the House Health Care Committee but was regrettably removed on the House floor.
A bill has now been delivered to you which lacks sufficient clarity about education and scope but still grants broad authority to a Board of Optometry that has historically taken liberties with legislation that may lack in clarity or intent. This issue is a complex one, and under better circumstances could, and should, have benefitted from considerably more quality reflection and time. Unfortunately, debate around this bill focused almost entirely on external reference points such as adherence to the Sunrise Report and the Oregon scope, as opposed to an informed examination of the actual procedures being authorized and the appropriate training and oversight necessary for optometrists to safely perform them.
It is important for you to be aware of the historic national perspective regarding increasing optometrists’ scope of practice. Washington is not unique in optometry’s efforts to seek such authority, despite the fact there has been no public outcry for such scope expansion. This has been a national goal of optometrists for years. Fortunately, few of those legislative efforts have been successful. Since 2015, only 6 states have passed legislation permitting any type of surgical expansion (laser or scalpel) for optometrists. By contrast, in that same time frame legislatures have rejected scope expansion proposals more than 60 times, in the interest of patient safety. Recently those failures have included our border states, Oregon and Idaho.
As you may be aware, last year California passed legislation with significantly greater patient protections than those in SSB 5389, but the bill was wisely vetoed by Governor Newsom. Governor Newsom’s veto message stated, “I am not convinced that the education and training required is sufficient to prepare optometrists to perform the surgical procedures identified. This bill would allow optometrists to perform advanced surgical procedures with less than one year of training. In comparison, physicians who perform these procedures must complete at least a three-year residency program."
Given all of the fundamental flaws and inconsistencies contained in SSB 5389, WAEPS and others think Washingtonians would be well-served by your issuing a similar veto message.
Stephanie Cramer, MD
President, Washington Academy of Eye Physicians and Surgeons