New star wars’ brewing over who uses lasers
Optometrists, ophthalmologists fire first
As laser technology redefines same-day surgery procedures, a national controversy is brewing over who may use them. Are they tools of surgery for physicians only? Or can other health care practitioners set the parameters and push the button?
In Idaho, optometrists are performing photorefractive keratectomy (PRK), a new procedure to correct nearsightedness that they say is not surgery. The Idaho State Board of Optometry in Boise said the procedure falls within optometrists’ scope of practice. Arguing that PRK is surgery, the American Academy of Ophthalmology in San Francisco, Idaho Medical Association, and Idaho Society of Ophthalmology, both in Boise, say the practice could endanger patients. They have sued to stop the optometrists.
Similar battles are likely to emerge elsewhere because of the wide variety of lasers and laser procedures, which differ greatly in complexity and potential risk, says David J. Goldberg, MD, JD, president-elect of the Wausau, WI-based American Society of Laser Medicine and Surgery and a dermatologist in Westwood, NJ.
"To put out a blanket statement and say no nonphysician can do any laser procedure puts the medical community in a precarious position," says Goldberg, who is also an attorney specializing in health care law.
Yet that is a position the Chicago-based American Medical Association (AMA) will consider this month at a meeting of the association’s board of trustees.
The AMA is considering resolution that would advocate limiting surgery including laser surgery to medical doctors, doctors of osteopathy, dentists, and podiatrists. AMA positions are not binding on anyone but may influence state legislatures and credentialing decisions at hospitals and surgery centers.
Not a turf issue’
"It’s not a turf issue. It’s a public safety issue," says John C. Nelson, MD, MPH, a member of the AMA board of trustees and an obstetrician/gynecologist in Salt Lake City. Nonphysicians do not have the extensive medical training or the legal responsibility and malpractice coverage of physicians, Nelson notes.
"It’s an issue of attempting to increase the scope of practice by law rather than training," he says. "It doesn’t take much of an imagination to say, if a nonphysician can use an excimer [for PRK], why couldn’t they excise a wart? Why couldn’t they open the abdomen? Why couldn’t they remove an appendix?"
Some lasers are easy to use, are highly automated, and present little risk to patients. Who is entitled to use them? And where do you draw the line?
The optometrists argue that they are simply correcting vision using laser light. In performing PRK, their only direct contact with the eye occurs "in a routine manager which is no more difficult or complicated than removing a foreign body and the rust ring caused by a metallic foreign body in the epithelium," according to the optometrists’ response to the lawsuit.
Ophthalmologists call the laser "a light-scalpel" and note the PRK "destroys tissue, a surgical act that results in irreversible changes to the eye."
Training is different
Without commenting on the PRK case, Goldberg notes the vast differences in the training required to use different types of lasers.
For example, the Q-switched Nd:YAG may be used to remove age spots, tattoos, and excess hair, he says.
"Those are very simple procedures with incredibly low risk," Goldberg says. "There’s no question that nurses are more than qualified to do that laser work, once appropriately trained."
By contrast, char-free pulsed CO2 lasers, which can be used for laser skin resurfacing to remove wrinkles, carries much greater risk to patient safety and should only be used by physicians, Goldberg says.
Set credentials laser by laser
For now, hospitals and surgery centers must develop their own credentialing rules without clear guidelines or state laws regarding who can use which laser.
What if the physician assesses the patient, sets the laser parameters, and asks a nurse to administer a certain dose of laser energy?
"I feel that nurses are qualified to do that," says Kay Ball, RN, MSA, CNOR, past-president of Denver-based Association of Operating Room Nurses and a perioperative consultant based in Columbus, OH. "It’s just like the doctor saying, I want you to give this much Demerol IM.’ It’s just implementing the order."
Nelson agrees, as long as the nurse is "working under the on-site, hands-on supervision of a physician." Nelson says the guiding principle should be one of training both in use of the specific laser and general medical training.
Goldberg advises same-day surgery managers to look at each laser and laser procedure individually when making credentialing decisions. "The only way to do this in a fair, ethical, and legal manner is to look at each laser and determine which are appropriate for a nonphysician to use and which are inappropriate," he says.
One area everyone seems to agree on: The Idaho lawsuit isn’t likely to be the last on this subject. "We’ll probably be talking about this for a few years to come," says Goldberg.
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