SB 492 seeks to set clinical training standards allowing optometrists to perform surgical eye procedures.

Surgical training legislation threatens patient safety

On behalf of ourselves and our counterparts at Loma Linda University (Michael E. Rauser), Stanford University (Mark S. Blumenkranz), and the University of California campuses at Davis (Mark J. Mannis), Irvine (Roger Steinert), Los Angeles (Bartly J. Mondino) and San Diego (Robert N. Weinreb), we express as individuals not representing our institutions our serious concerns about Senate Bill 492, a bill pending in the California Legislature that claims to establish clinical training standards allowing optometrists to perform scalpel and laser surgical eye procedures and medication injections.

This bill is fundamentally flawed in that it does not clearly and specifically require sufficient and adequately supervised surgical training on human patients.

We certainly respect our optometric colleagues. However, having been responsible for teaching countless ophthalmology residents and fellows during our careers to do the types of surgery that would be authorized for optometrists under this bill, we can assure you — without any hesitation — that we do not feel that anyone would be qualified or competent to perform even just those surgeries by completing the training required by this legislation.

Doing surgery requires not only the development of technical skills but also — and almost certainly more important — developing the judgment to choose the right procedure for the patient, assess the risk for complications, and manage complications — including rare ones — that may arise during the procedure. This can only be gained by broad, mentored experience during training.

The experience that would be afforded by doing the limited number of procedures outlined in the bill cannot possibly be sufficient for development of either technical skills or surgical judgment.

Furthermore, doing a sufficient number of cases is vital in order to identify and treat complications, which — contrary to the suggestions of our optometric colleagues arguing in favor of the bill — do occur. The minimal experience called for under SB 492 would not provide the trainee with sufficient exposure to the management of complications needed to be adequately trained.

The bill focuses on minimum numbers. Yet, minimum numbers are only a beginning. More important is assessment of competence. That is our job as supervisors of surgical training — individuals with experience gained from thousands of surgeries. In short, no trainee completes our programs — regardless of numbers — until the faculty is comfortable with their performance and surgical abilities.

Indeed the specific numbers of a given procedure are far less important than the constellation of experience acquired doing not only those surgeries, but also similar surgeries. The overlapping skills — for example using a scalpel, placing sutures, observing tissue response to laser treatment, and performing injections — all reinforce one's ultimate competence with any procedure using similar techniques.

We are aware the bill has been portrayed as “[requiring] optometrists to do more training procedures than what is required of ophthalmologists.” With all due respect, that is patently misleading. The minimal training proposed in the bill stands in stark contrast to the hundreds of such surgeries performed during residency training programs by ophthalmologists.

The citizens of our state deserve far better than the superficial and inadequate training that is provided for in SB 492, which would produce “surgeons” who almost certainly would have no basis to know what they are doing.

Anyone — optometrist or ophthalmologist — that might be trained must have sufficient experience to achieve competence. This bill does not even come close to approximating the needed experience.

We strongly encourage the Legislature and the governor to reject this threat to patient safety.

Susan H. Day is professor and chairwoman of the California Pacific Medical Center. Stephen D. McLeod is professor and chairman of the UC San Francisco Department of Ophthalmology.


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