As the Director of Diversity, Equity, Inclusion and Belonging at SUNY College of Optometry, I had the opportunity to read the article, “The Role of Race and Ethnicity in Optometry” (January 2022) by Brian Chou, OD, and am inclined to respond. There are several misleading or inaccurate points mentioned, starting from the first sentence, which states, “While race and ethnicity are often used interchangeably, race has to do with biological and physical features which generally cannot be hidden…” and carries on from there. 

The most recent AMA guidelines clearly state that race and ethnicity are social constructs without biological or scientific meaning. The Academy and the most up-to-date literature are clear on the fact that race is ill-defined, and often assumed by clinicians based on phenotype without any rigor. Scientists and clinicians are beginning to be aware that “race” has been a proxy for socioeconomic status and other social determinants of health in much of our analysis of data, and are working to reframe what it means in our profession. 

With reference to a genetic basis for race-focused medicine, the field of epigenetics has shown that gene expression may also be affected by social determinants of health. Although there are important associations we use to help quickly categorize people based on “race,” we must start to recognize that there are many structures and factors behind those associations. Articles will continue to associate certain conditions with race but should also mention the other important factors to take into consideration. I do not think this was adequately done in Dr. Chou’s article. 

The use of stereotypes of what the typical Asian or Black patient should or should not get screened for or the types of frames you should stock are inaccurate at best. The relationship between Black and Latinx patients and diabetes is rooted in sociological factors widely acknowledged to be present. This article lacks nuance and context.

As a widely read magazine in our profession, Review should be on top of the new interpretations of these categories. We cannot reinforce stereotypes; we have moved beyond these practices. 

—Joy Harewood, OD

SUNY College of Optometry

New York City

From the Editor: We at the publication share your goal of helping the profession move away from simplistic and outdated modes of thinking about and interacting with patients.

The January issue’s theme, explored over the course of seven articles, was the importance of viewing the patient as an individual who comprises a unique set of traits derived from such varied sources as their genetic makeup, health status, socioeconomic experience, cultural/familial upbringing, sexual orientation and more. Dr. Chou’s assignment was to review racial and ethnic associations documented in the medical literature and widely used in practice, even if they do rely on generalizations and assumptions. 

Either in that article or elsewhere in the issue, we should have acknowledged race as a social construct and the limitations that arise from it; the oversight lies with us on the editorial staff and not Dr. Chou, who wasn’t asked to delve into that aspect. He did also touch on the influence of socioeconomic factors and epigenetics in these associations, however.

In short, the aim of the issue was to help optometrists learn to view and relate to each patient as a unique individual. It was an ambitious goal and I don’t doubt we could have included more nuance in a number of cases. We look forward to continued exploration of these newer and more challenging topics to help ODs improve their clinical care and cross-cultural fluency.

Rethinking Comanagement

In the April issue’s letters section, Dr. Don Stover wrote, “I generally don’t make money on post-op (comanaged cataract) visits. Wouldn’t it be nice if cataract surgery was one fee and the post-op care was another fee? This might support better post-op care.”

This was a hypothesis of mine and was also promulgated by a legal expert in one of our trade papers back in 2017. So, I floated the idea to several of my comanagement referral docs, but they liked the status quo. One of my busiest referrals said no, because he liked to be a more direct part of the surgical care through the Medicare comanagement billing process. I was surprised by this. To me, the OD/MD (or DO) doctor’s behavior and the care rendered would be identical. Only the billing codes would be different, and they would be simpler. 

I still think Dr. Stover’s intuitive idea is good and workable. It seems simpler and more transparent for the patient to return to the referral optometrist’s office and for that doctor to bill under the E&M codes or the eye codes, just like for any other patient. Indeed, when a surgeon has an emergency or takes ill, the surgeon’s non-comanaged patients are often seen by an unrelated ophthalmologist, who is then allowed to reasonably bill for their services. The bills are reasonable because the visits are brief, and extensive testing is not needed.

—John Maher, MD

Torrance, CA 

Instructor at Ketchum University School of Optometry, Anaheim

Tech Training Needed 

I have a few questions for the colleges of optometry and other educational institutions all across America. How many have certified programs to train people to be an optometric assistant?

In my 46 years’ experience as an optometrist, I would say it is difficult if not impossible to find an employee who has any basic eyecare knowledge regarding optics, eye anatomy and the fundamentals of eyeglasses.

Are there no technical colleges that consider a one- to two-year program to teach basic principles of optics and eye care to prepare someone to become a valuable part of the healthcare system? Is the AOA involved in any way to  remedy the need for this training?

I see ads by small colleges in my state offering training to be a medical office assistant, pharmacy technician, phlebotomy technician, nurse (of various levels), radiology tech and even massage therapist—but training in eye care is left out. Why? Who is responsible for this lack of important education? 

Every employee that I have in my office has been partially or completely trained by me and my experienced assistants. My optician even has done most of her training herself or by me. I am lucky to have many experienced and competent assistants and technicians. I would like to have more.

The optometry schools or technical colleges need to address this lack of qualified people to work in optometric practices. It has gotten even worse since the pandemic.

—R. Thomas McHugh, OD

Morehead, KY

Hold the Line on Eye Exams

I have noticed that many commercial and private practices have become increasingly apathetic about patient care and dilation. 

If we are held to the same standards as medicine (ophthalmology), why are we not informing patients who do not want dilation that their optometrist won’t examine them if the patient does not allow them to not do their job?

Non-dilated photos are not an acceptable alternative. Widefield imaging is not an acceptable alternative. We are responsible to the patient regarding their eye health when they walk through the door. Widefield imaging is an asset, but it misses the boat when the superior and inferior retina cannot be seen and the doctor does not make an effort to view these areas adequately. 

I agree that most patients only want what their vision plan will pay for—eyeglasses and contact lenses. The doctor is the guardian of their eye health and, in many instances, their general health. 

I propose that it is time to stop this foolishness. Vision care plans need to change their reimbursement schedules. I feel $40 is reasonable for a refraction. (Consider what ophthalmologists charge, and note that the refraction is done by a technician in many cases.) However, that is not reasonable for a full, dilated examination.

All patients—especially children—deserve the most comprehensive treatment upon initial presentation. Would one consider that examining a child under dilation is of utmost importance? Most cannot report their issues well enough to the examining doctor. 

Maybe it is time to turn away a patient who will not let us do our job.  We as optometrists are afraid to “rattle the cage” of our patients! If we want additional privileges such as minor noninvasive surgeries, the time has come for us to act like the professionals we are supposed to be and fight back against inadequate eye care. Whether you practice in Florida or Oklahoma, whether you do or do not belong to the state association, your profession is at a significant crossroads. Let’s do our job. Make our profession the guardian at the gate. Do not let a patient dictate to you what is right or wrong. 

—Russell J. Raye, OD

West Palm Beach, FL