Vermont Legislature SmartTranscripts:

[Chair Matthew Birong]: Great to count. It's getting hard. Good morning, everyone. It is Wednesday, May 6. We are picking up work for the introduction and walkthrough on S-sixty four, an act relating to amendments to the scope of practice for optometrists. And we were gonna be joined by the reporter of the bill, but he's not here, so we are gonna skip right over to counsel so she can run us through the words on the page.

[Jen Kirby, Office of Legislative Counsel]: Good morning, Jen Kirby from the Office of Legislative Council. So do you like words up on the screen?

[Chair Matthew Birong]: Sure. Yes. Only if you bump up the font for my plus eight eyes.

[Vice Chair Lisa Hango]: Don't put it on.

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: Yeah, the brightest topicals.

[Chair Matthew Birong]: Playing to the crowd.

[Jen Kirby, Office of Legislative Counsel]: All right, here we go. S-sixty four, Annaprolating to Amendments to the Support of Practice for Optometrists. So this bill amends an existing chapter in Title 26 on optometrists. It starts out by amending the definitions section, specifically around the practice of optometry. Sort of the big picture on what we're gonna see in this bill is that it would create a new advanced therapeutic procedures endorsement that would allow optometrists with appropriate training to perform additional procedures. It amends the definition of the practice of optometry. First, it makes some, minor modifications to the existing language, but the main part is that it adds, to the list of, of the different practices that an optometrist can do, it adds for an optometrist who holds an advanced therapeutic procedure specialty that gets created in this build. They can also, as part of the practice of optometry, perform the following advanced therapeutic procedures. There's a long list. I don't know if you want me to go through all of these pronunciation to be determined, or if you just want to let the experts tell you what they all mean.

[Chair Matthew Birong]: Sorry.

[Vice Chair Lisa Hango]: I guess I wanted you just to run through the names and then maybe if we have questions, we can ask the subject matter what that means. Great. Yes.

[Jen Kirby, Office of Legislative Counsel]: So, So this would allow them with the, again, with the advanced therapeutic procedure specialty to perform surgery to remove lesions from the eye and annexa and accompanied restoration of tissue, including only the following. So this is an exclusive list, excision and repair of non recurrent Schalazia, which I'm finally learning how to pronounce.

[Chair Matthew Birong]: All right.

[Jen Kirby, Office of Legislative Counsel]: Excision and biopsy of non recurrent lesions of the adnexa, which I understand is the area right around the eye. Is that what's phonopronouncer? Okay, thank you. Without characteristics or obvious signs of malignancy, excluding any lesion that involves the eyelid margin, including the lacrimal supply or drainage systems, that's your depth stuff deeper than the orbicularis muscle, don't know that one or larger than five millimeters in diameter, closure of wounds resulting from removal of a lesion, repair of an eyelid laceration not larger than two and a half centimeters, not deeper than the orbicularis muscle and not involving the eyelid margin or lacrimal drainage structures and corneal cross linking. So that was all under this list of surgery. Now we have the following laser procedures, laser capsulotomy, laser peripheral iridotomy, and laser trabeculoplasty, and then the following injections, Injections of therapeutic pharmaceutical agents into the eyelid or its adnexa, including into the subconjunctival space and including injections for the removal of Schalazia and injections to administer local amphithesia. Injections to perform fluorescein angiography, injections of epinephrine for treatment of anaphylactic shock, and if authorized by the Commissioner of Health during a public health emergency, vaccinations for systemic health reasons. Then it specifies that the practice of optometry does not include performing any of the practices set forth in an upcoming section. So this is expanding for these folks, with the advanced therapeutic procedures specialty, types of practices that they can engage in. It's an exclusive list, exhaustive list, and it does not include performing things that'll be included in the prohibited acts list coming up. And we have a definition of adverse event. This is taken from an existing statute on the health care system surveillance and safety surveillance system, which is administered by the Department of Health and involves reporting of adverse events. So, using that same definition, adverse event means any untoward incident, therapeutic misadventure, iatrogenic injury, or other undesirable outcome directly associated with care or services provided by a healthcare provider or facility as those terms are defined in the healthcare statutes. A definition of therapeutic pharmaceutical agent, which is a prescription or non prescription drug used or prescribed for diagnosis, prevention, treatment, mitigation of abnormal conditions and pathology of the human eye or Exignixa does not include any drug or substance that must be administered by intraocular injection or intraocular implementation, except as authorized specifically by one of the provisions in that definition for an optometrist holding an advanced therapeutic procedure specialty. And it does not include any drug or substance that is prohibited under the prohibited procedures list in what will come up soon in section seventeen twenty. That's just definitions. Now we get to renewal. There's an existing statute on renewal requiring optometry licenses to be renewed every two years. This would add new language requiring a licensee who holds an advanced therapeutic specialty to, during each two year license period, complete an additional five hours. Let's roll back up. There's 40 of continuing education for regular license renewal now. And for anyone with the advanced therapeutic procedure specialty, there would be an additional five hours of continuing education approved by the board of optometry in the advanced procedures. Section three is that list of prohibited practices that was referenced in the definition section. This prohibits an optometrist from performing any ophthalmic surgeries with or without the use of lasers or injection procedures other than those set forth in that practice of optometry definition in the first section. And it includes, the prohibition includes the following procedures that an optometrist is prohibited from performing. Do you want me to go through these? Do you want experts to go through these? Or who do you

[Vice Chair Lisa Hango]: want to do? No. I don't want to put you through the

[Chair Matthew Birong]: There's some big words.

[Vice Chair Lisa Hango]: There are a big words I'm looking It's just like

[Jen Kirby, Office of Legislative Counsel]: most of the stuff. First part.

[Chair Matthew Birong]: We will defer that section.

[Jen Kirby, Office of Legislative Counsel]: All right, great. So, just beyond notice. All right, so you can see there's a list of 23 items. It also prohibits an optometrist from prescribing or administering a drug or other substance that it's listed as a Schedule I or II controlled substance under the Federal Controlled Substances Act, except for this small exception. And the small exception is that an optometrist optometrist may prescribe or administer hydrocodone in combination with analgesics. So this is something like Vicodin provided that the optometrist shall not prescribe more than a seventy two hour supply of hydrocodone and shall not provide any refills of the prescription. Section four creates the new sub chapter on advanced therapeutic, the advanced therapeutic procedure specialty. So I'm refocusing an existing sub chapter that I think has either nothing or one section in it. So, this allows an optometrist who is licensed with the regular optometrist license to apply for an advanced therapeutic procedure specialty that authorizes them to perform the advanced therapeutic procedures that are listed in that definition section. The qualifications. In general, an optometrist must obtain the advanced therapeutic procedure specialty in order to perform the advanced therapeutic procedures. And it allows the board to grant the specialty to an applicant who is licensed as an optometrist under our licensure statutes, meets the applicable requirements for education and demonstrated competency that you'll see in this section, and has completed the examination requirements that you'll see also in this section. For education requirements, in order to obtain this specialty, there's a difference in time. So, an optometrist who graduated from optometric school or college prior to 2019 must have completed a postgraduate course sponsored by an organization approved by the Board of Optometry that has a minimum duration of thirty two hours and included the following didactic classroom instructions. So, classroom work as opposed to clinical work you'll see coming up. So a minimum of thirty two hours and included laser physics hazards and safety, biophysics of lasers, laser application and clinical optometry, laser tissue interactions, laser indications, contraindications, and potential complications, gyneoscopy, again, you have to ask somebody else, laser therapy for open angle glaucoma, laser therapy for angle angle closure glaucoma, posterior capsulotomy, common complications involving lids, latches, and lacrimal system, medicolegal aspects of anterior segment procedures, peripheral iridotomy, laser trabeculoplasty, minor surgical procedures, overview of surgical instruments, asepsis and occupational safety and health considerations, surgical anatomy of

[Vice Chair Lisa Hango]: the eyelids,

[Jen Kirby, Office of Legislative Counsel]: emergency surgical procedures, Scholesian management, techniques for and complications with local anesthesia, almost done, anaphylaxis and other emergencies that may occur in an office setting, radio frequency surgery, post operative wound care, and clinical or laboratory experience that includes both video demonstration and in vitro observation or participation. That's So all for anybody who graduated before 2019. An optometrist who graduated in 2019 or later does not have to do that additional postgraduate coursework. My understanding, it has now been incorporated into their, regular course of studies in order to obtain the specialty. Preceptorship requirements and competency demonstration. In order to demonstrate competency for the specialty, this requires the optometrists to complete a preceptorship during which they gain at least eight hours of clinical training supervised by a preceptor, and they demonstrate clinical proficiency with hands on experience performing the following procedures on live human patients. If you do at least two laser trabeculoplasties, at least two posterior capsulotomies, at least two laser peripheral aerodotomies, at least two Scholesian excisions, at least two Scholesian intra lesional injections, and at least two excisions or drainages of an authorized lesion of two millimeters or greater in. Again, we have to do at least eight hours and perform all of these procedures. The preceptor must either be an optometrist who has a substantially similar scope of practice who has been licensed in Vermont or any other US jurisdiction to provide the advanced procedures that are in that expanded scope section in the definitions for at least three years, or an ophthalmologist who's an MD or DO, but a physician. The preceptorship must include direct and in person supervision of the optometrist by the preceptor. Can't be remarkable. Preceptorship must take place in a state in which the preceptor is licensed and authorized to perform the advanced procedures. And the preceptor must certify that the gaptometrist has competently completed the required procedures and provide a log of those procedures to the board. There are also examination requirements. The applicant must successfully pass written and clinical examinations administered by the National Board of Examiners in Optometry, including its injection skills examination, its laser and surgical procedures examination, and any other exam required by the Board of Optometry by rule. There's also the potential for someone to receive the specialty by endorsement that allows the Board of Optometry to issue the specialty to an applicant who is licensed and in good standing in another US jurisdiction and who has an expanded scope of practice that is substantially similar to or broader than the scope that would be permitted by this subchapter, and has been in good standing in that expanded scope of practice in the other jurisdiction for at least three years. And it allows an optometrist to receive their specialty here by endorsement to serve as a preceptor for other optometrists as well. Finally, it requires an optometrist to report any adverse event, hence the definition of adverse event, related to an advanced procedure within thirty days following the event. Section five moves that one section that is currently in subchapter five in this chapter to another section, just redesignates it. And the Act will take effect on 07/01/2028.

[Senator John Morley (Orleans District)]: Yep. Final. A lot of words.

[Chair Matthew Birong]: Rabbiujin, then Morgan. Did I hit that right?

[Senator John Morley (Orleans District)]: Was just kind of like jump balls first.

[Representative Kate Nugent]: I have a few questions, but I just For the reporting date for the adverse event, how that compares to other medical practices and reporting requirements?

[Jen Kirby, Office of Legislative Counsel]: I don't know the extent to which there are reporting requirements for adverse events in other, specifically in other professions. I know there are for adverse events that occur in a hospital, which is where this came from. And I'm not sure that the timing is similar looking at the OPR and medical. I'm not aware of any other

[Emily Tarr, General Counsel, Office of Professional Regulation]: reporting requirements. Does it mean that there aren't any? I'm still getting my

[Lauren Hibbert, Deputy Secretary of State]: We can certainly look. Representative

[Senator John Morley (Orleans District)]: Morgan? No, I just a little bit of levity this morning, I think our Madame Ledge Counsel is halfway, in addition to having her juris doctors, on her way to be an optometrist, and the pronunciation of all those terms and getting through that. Think that was very well executed.

[Jen Kirby, Office of Legislative Counsel]: Thank you. I'm going to assume there are significantly more involved.

[Chair Matthew Birong]: Seriously, this isn't an unfortunate, rare event.

[Senator John Morley (Orleans District)]: You'll see adding a shingle to the wall.

[Chair Matthew Birong]: Fair enough. Just a little levity from you. Any other questions for counsel? Want to be conscious of her time and her need to gather committee and that a hand, Yep.

[Representative Kate Nugent]: Is there a

[Vice Chair Lisa Hango]: reason why the effective date is pushed out till 2028?

[Jen Kirby, Office of Legislative Counsel]: Yes, I believe that is to give time for the Office of Professional Regulation to go through the rulemaking process and get ready to issue the advanced therapeutic procedure. That's some work for them still to do.

[Chair Matthew Birong]: Seeing nods from both OPR and the reporter of the bill. Yes, So

[Vice Chair Lisa Hango]: Yes.

[Jen Kirby, Office of Legislative Counsel]: In fact, the bill was introduced last year in 2025 with an effective date of 2027. And so the sole amendment in the Senate was to push that effective date out one year.

[Chair Matthew Birong]: Okay. Questions for council. Okay. Thank you so much. Sure. Yes.

[Senator John Morley (Orleans District)]: We're going to toggle over

[Chair Matthew Birong]: to Senator Morley. How are doing, sir? Good to see you again. You. Welcome. Thank

[Senator John Morley (Orleans District)]: you, John Morley, Senator Orland's district on health and welfare, and gov ops, obviously. Was a long bill, tough bill, and I, in my own mind, said, What's the most important thing? And it's safety, and can we save Vermonters money? So those were the two criteria in my mind that I really had to make sure checked the boxes, and I think it is going to save money. I'm from a very rural area. There's approximately 33 ophthalmologists in the state and approximately 133 optometrists, and there's a lot of traveling from my area having to go to ophthalmologists, and we have quite a few optometrists. So then I became, I wanted to know what these procedures were, and I did a lot of research on open angle glaucoma, pigmentary glaucoma, and I actually went and found the definitions of all of them so I understood what I was talking about because I didn't want to get blasted on the Senate floor.

[Chair Matthew Birong]: Good instinct. Yeah.

[Senator John Morley (Orleans District)]: And so I went through each one line by line and finally, and actually talking to ophthalmologists and also optometrists and specialists and lobbyists, and I'm sure you're all getting lobbied very hard and you're hearing from a lot of people. I took that consideration as well. They all had good ideas, good facts, but ultimately it's our responsibility and decision to determine if this bill moves forward or doesn't. And so looking at the guardrails that were set in here, this was an OPR bill and OPR we put a lot of trust in, Office of Professional Regulation. And they had done a Sunrise assessment on this and have looked at it and their opinion that these practices were safe to conduct in optometry. The other issue that I looked at was in a lot of other states. I think another one just passed. I can't remember. 14 or 15 states are currently doing this. The other issue I had with it was people that are graduating in optometry weren't able to in the state use their full scope of practice, and so it wasn't convenient for people that were graduating to want to come to the state of Vermont because it didn't allow them to practice their full scope. Talking with some of those individuals, they thought it was a good idea that Vermont do this, that it would help induce them to want to come to this state. And I think that we're falling behind some other states. So safety costs and education is what I've been doing on this bill. And so those are my The other thing I just want to point out too, I don't know how many optometrists that have been in the field for a long time are actually going to go and do what's listed in here in order to get the expanded scope of practice. It's available to them through this bill, but I'm not sure how many of them will actually do it. After talking to some of them, some will, some won't. So I just wanted to make sure that's clear on that.

[Chair Matthew Birong]: I

[Representative Chea Waters Evans (Ranking Member)]: mean, aside from the fact that we are not eye doctors and it makes me feel nervous to make decisions about stuff like this. I trust, you know, the health care committees and stuff. But here's a question I have for you. And I'm wondering if you heard any testimony about this or talked to anyone about it. If if I if I had a a job or a business, and I could do one thing and make $20, and then I could then my options for what I could do with my business were expanded, and I can make $200 in the same period of time, I feel like I would choose to do the thing that made me more money, generally speaking, as a business person. So my question is, if we are saying that for optometrists, this would give more access to people who are in areas where they need those things. What about, like it already takes six months to get an appointment just to get your eyes checked, an optometrist. And I'm wondering if you heard testimony about how this would affect sort of the daily access for people who maybe don't need a more advanced procedure and just need like a regular eye checkup. I worry that it's actually, you know, people are going to be choosing to do these other procedures and it's going to further limit the availability of

[Senator John Morley (Orleans District)]: Well, remember, you only have three ophthalmologists, 33 ophthalmologists, that's two. So I'm thinking it's going to make it better if they can perform some of these procedures. It's going to probably lessen a little bit on the ophthalmologist side, and it will add a little bit additional burden on the optometrist. I think that's what you're getting at, isn't it?

[Representative Chea Waters Evans (Ranking Member)]: I'm worried about the access. So if you live somewhere where there's maybe not a lot of access to an optometrist, and that person's already kind of doing very busy, right? And then sort of the regular or routine eye exams and services that are available, I worry that those are going to be even more limited because, I mean, I'm making myself

[Senator John Morley (Orleans District)]: clear. No, no, I just understand what you're saying.

[Representative Chea Waters Evans (Ranking Member)]: Would choose it to say, I'm gonna do the things that get me more money. I'm gonna do the things that make my business stronger. And that to me, it seems like it would be the things that-

[Senator John Morley (Orleans District)]: I can tell you that I didn't hear testimony saying that this was going to be a huge concern

[Chair Matthew Birong]: as

[Senator John Morley (Orleans District)]: far as services being provided. I did not hear that. One other thing I just want to another thing that kept going through my brain as I was thinking about this was if you were an optometrist and your whole profession and your livelihood is on your license, Would you do those procedures if you didn't feel you were capable to do that? I would say no because they don't want to put themselves in that position because that was an argument that was made that they could really hurt people and so on and so forth, and then after talking to them, it like, No, feel uncomfortable doing something. I'm not going to do it. My whole livelihood is based on this profession. That was another thing that really stuck out to me. Like I said, some will want to expand their scope of practice, some will not want to extend their scope of practice. That was something that I just thought about.

[Vice Chair Lisa Hango]: We took up a similar bill last biennium to look at this, and there was a lot of disagreement between the optometrists and all of this. So I'm wondering if folks are now on the same page or maybe why it's changed, what are you doing? Just

[Senator John Morley (Orleans District)]: so you know, I worked very hard on trying to get both sides to come together and agree on certain aspects, and that it didn't work out. They very much disagree on this bill, but they work together every single day. Thank God they're all professionals, and they're doing what's best for their clients and providing the services that customers need. I don't envision this causing a big, huge rift among them in the services that they provide, but they do certainly disagree, Representative, on this bill. I guess this has been going on not well before, I mean, I just got appointed, so I kind of fell into this.

[Chair Matthew Birong]: The conversation has a lot of patina on it.

[Senator John Morley (Orleans District)]: Yeah, which I learned throughout this process, but I also thought it was a good bill, was an important bill, and it met the criteria for me to vote favorably on it. And the Senate, it was a voice vote, there was a lot of sponsors on the bill, and in my opinion there were only three no votes, so it was like 27 to three. I may be off a little, little bit, but it was a very strong vote from the Senate to approve this.

[Vice Chair Lisa Hango]: And out of committee was in it?

[Senator John Morley (Orleans District)]: Out of committee, a little different story. Came out of gov ops five-zero and it came out of health and welfare three-two.

[Representative Robert Hooper]: This is fun. Who voted now?

[Senator John Morley (Orleans District)]: It was the chair and Senator Cummings. So senator Gulick, senator Benson, and myself vote in favor of the bill.

[Representative Robert Hooper]: Not dissimilar to dentistry. Everybody's a dentist, and then there are specialties.

[Senator John Morley (Orleans District)]: Yeah.

[Representative Robert Hooper]: What do we look at?

[Chair Matthew Birong]: With the waters in this.

[Representative Chea Waters Evans (Ranking Member)]: So you're on both the health.

[Chair Matthew Birong]: He is uniquely positioned to serve in both committees.

[Jen Kirby, Office of Legislative Counsel]: Alright. I guess I'll call back

[Representative Chea Waters Evans (Ranking Member)]: before I ask you this question. Okay. So I'm I'm equally as cranky about parts of this bill as I am about this early childhood education bill that we had just been working on, which is that I feel like I feel like if we are staying in our lane as a government operations people, it seems much more like something important to looking at those aspects of the bill. It seems like a little easier to wrap my brain around us making that decision, not that we are not wonderfully qualified and intelligent people, but, you know, it's kind of out of our wheelhouse, like education and eyeballs. So can you talk to me about it? Can you compare the conversations you had in Govox and and help them up and also even your own process, your own thinking process about approaching it from those two really different sides? Because that's a part I struggle with is like the the health aspect of it. And it because like from from the gov ops point of view, it seems kind of straightforward, but it's the other part that's that trips me up a little bit. But I guess we're not in this room to make decisions about the health care portion. Technically. We're looking just at the government operations and OPR point of view.

[Senator John Morley (Orleans District)]: Representative, So you are absolutely going to hate my answer.

[Representative Mary-Katherine Stone]: Oh, I can't wait.

[Chair Matthew Birong]: Great to you.

[Senator John Morley (Orleans District)]: I came in in January. This was voted out prior to me being on Seneca Bombs.

[Representative Robert Hooper]: Good point.

[Representative Chea Waters Evans (Ranking Member)]: They did at the very beginning? Yes. They moved it last night.

[Jen Kirby, Office of Legislative Counsel]: Oh, last night.

[Chair Matthew Birong]: Last night. Last Last so it was moved out like ways in the I

[Senator John Morley (Orleans District)]: can tell you that every day sitting in Gabbos, I was hounded by the Senators like, How's it going in Senate Health and Welfare? How's it going in Senate Health and Welfare? This is a really great bill. We passed it unanimously. We looked at it, we heard all the testimony. Please, Senator Morley, try to do what you can to get it out of Health and Welfare. I cannot answer your question on the Senate gov ops side of it. I apologize for that.

[Representative Chea Waters Evans (Ranking Member)]: I don't hate that answer. That's a fine answer.

[Senator John Morley (Orleans District)]: Well, I wish I had one for you. Put it that way.

[Jen Kirby, Office of Legislative Counsel]: That's the part I've

[Representative Chea Waters Evans (Ranking Member)]: been thinking about the most.

[Senator John Morley (Orleans District)]: If you would like, I can try to get the chair or another. Becca White was a sponsor, lead sponsor on the bill, and she was in GOV ops during that time period, and I can certainly have her speak with you folks about this committee.

[Chair Matthew Birong]: I think that would be helpful. Yep.

[Vice Chair Lisa Hango]: Is it Chittenden who brought it to us last year?

[Chair Matthew Birong]: Senator White is the lead sponsor on the Senate bill. I am the lead sponsor on the House bill. They were mirrored if language is finished. Anything else for Senator Morley?

[Representative Mary-Katherine Stone]: I'm just having an existential problem with the fact that the legislature is looking at the scope of practice for any medical profession. I can see valid arguments on both sides. This happens in a lot more professions than people think. I will say that I can share something about my profession that I found very strange. As an occupational therapist who graduated in 2013 from grad school, I was trained to use physical agent modalities. So those are things like TENS units, ultrasound, things that aren't surgical, but they do carry a risk for causing harm if misused. But I was trained to use that during my schooling. And then I moved to Vermont and found that our state does not allow me to use them without further education and receiving further credentialing, even though I have 145,000 of student loan debt and three years of schooling to use them, I would then have to pay more money and go and do more. And there's like a patchwork of that happening across The United States with OTs and physical agent modalities. So very similar to optometrists where you go to school, you get training, and then you move to a state and they tell

[Chair Matthew Birong]: you, you can't

[Representative Mary-Katherine Stone]: do these things. So I understand, but I just want to say aloud that I have kind of a existential problem with us as legislators.

[Vice Chair Lisa Hango]: We're not

[Representative Mary-Katherine Stone]: doctors or optometrists or ophthalmologists making decisions about things when even our own legislative council did a great job but was struggling to get through some of the terminology in the bill.

[Senator John Morley (Orleans District)]: And so that's why I personally represent relied on a lot of experts. Yeah. Well, my history and OPR has done a fantastic job and has done a lot of research on this, just so you know. So that made me feel my comfort level a lot.

[Representative Mary-Katherine Stone]: Right, and I also just want to name that in West Virginia, there was a issue with a bill that they passed and ended up getting struck down at first because the profession went a step further and was doing things for their own licensure outside of the legislature. And then a judge found that that was not okay, that they kind of like extended on their own. So I just wanna make sure that that doesn't happen here and that people are, like, we make it clear that a licensing board can't take this a step further and start adding things to it on their own because that's when states have gotten into trouble when they start passing laws like this and then the boards take it upon themselves to expand even more. I just want to

[Vice Chair Lisa Hango]: name it.

[Representative Robert Hooper]: Well said, Rush, but does that mean you didn't know?

[Representative Mary-Katherine Stone]: I'm not saying which way I'm going. I'm just saying if you research bills that have passed in other states, the ones that have gone down poorly have been in states where we haven't made it clear that if we go this path, that OPR will be the gatekeeper for this kind of stuff and that licensing boards then can't say, Oh, great. We're gonna also add, in addition

[Lauren Hibbert, Deputy Secretary of State]: to some of these things that we

[Representative Mary-Katherine Stone]: can do with eyelids, we're also going to expand to do things with people's eyelashes. That's not true, but you know, whatever.

[Chair Matthew Birong]: I got a here, got Hango, I got Nugent, I got So

[Vice Chair Lisa Hango]: I have a few things. I appreciate that Senator Horley did his due diligence on getting educated on these subjects because they are really densely medically related. And that's why I'm really grateful that we were able to have the House Health Care Committee weigh in before we took our turn in weighing in on this bill. That was really helpful for me. Also, we will post it at some point soon if it's not posted already. But we've got a nice report from NCSL on what other states are doing. So that's really helpful. And thanks to rep Waters Evans for asking for that. And also, I just want to thank Senator Morley for being brave enough to report this bill after its long history. But we appreciate you being here. Probably we should talk about the fact that House Trump Care has voted this bill out.

[Chair Matthew Birong]: And I believe it was a ten-one-zero, if I recall. I think so. Got Nugent, Hooper is in Waterloo.

[Representative Kate Nugent]: I think I have questions for the subject witnesses, actually. It's what I'm realizing.

[Representative Robert Hooper]: We'll grab Hooper. How close did you come, Senator, to creating peace between these war and crime? Not very close. I cried.

[Senator John Morley (Orleans District)]: You know how you can say, Go out in the hallway, come together, try to resolve this, bring it back to us, work on it, massage it. No massaging happened. They

[Representative Robert Hooper]: had a licensure issue on that too.

[Senator John Morley (Orleans District)]: I tried.

[Representative Robert Hooper]: The ten-one,

[Chair Matthew Birong]: Who voted no on that? I believe it was Rev. Rutgers.

[Representative Robert Hooper]: I believe.

[Chair Matthew Birong]: Guess, are you finished, sir?

[Representative Robert Hooper]: Yeah. No, I've made my jokes.

[Chair Matthew Birong]: All right, we're passing the microphone over to the representative.

[Representative Chea Waters Evans (Ranking Member)]: All right, this is just one very informal question. Did you upset somebody that you had to do this, or is this a new guy hazing kind of situation where they got eaten They all

[Chair Matthew Birong]: are a bit more fraternal

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: in the upper chamber,

[Chair Matthew Birong]: aren't they?

[Senator John Morley (Orleans District)]: Oh, I also have to say that I'm also the clerk for the committee, being the new And individual on worked, like I said, I worked on this pretty hard from the beginning, and I was trying to work with everybody, and I just kind of took it on, and as I was, I called on the roll and then of course the chair asked, Who would like to present a report on the floor? And then she looked at me. So I knew I was going to be presenting the report on the floor. And I didn't mind that actually. It made me really focus in and learn as much as I could about it and I was prepared and it went all right.

[Representative Chea Waters Evans (Ranking Member)]: Yeah, it's probably good that you were fairly neutral and that you weren't here for a long history of it.

[Chair Matthew Birong]: Fresh eyes.

[Representative Chea Waters Evans (Ranking Member)]: Yeah, that's right. All right, thank you.

[Senator John Morley (Orleans District)]: Anything else? Looks like Chris Kelly has fun, I guess. There's always a lot of laughter. That's a good thing, right?

[Representative Robert Hooper]: Yeah, otherwise, you'd be quiet.

[Senator John Morley (Orleans District)]: Are you all set, Mr. Chair?

[Vice Chair Lisa Hango]: Thank you.

[Chair Matthew Birong]: Thank you. No, I'm just kidding. Thank

[Senator John Morley (Orleans District)]: you so much.

[Chair Matthew Birong]: Appreciate it. Don't get it blasted on the board. Right. However, this punchy I'm getting handed fresh scripts. It's good to go. All right, up next, we are going to go to Deputy Secretary of State. Whomever you'd like to join you. And Representative Coffin is not here, so feel free to advocate his chair.

[Lauren Hibbert, Deputy Secretary of State]: Good morning. For the record, Lauren Hippert, Deputy Secretary of State, and I have with me

[Emily Tarr, General Counsel, Office of Professional Regulation]: General Tarr, General Counsel for OBR. Thank you

[Lauren Hibbert, Deputy Secretary of State]: so much for having us. We did file testimony. I think I would like to just jump right to some questions that I heard and then have Emily talk more about what this bill is actually changing in the scope, if that's Okay. Because I think a really important thing for this committee to remain grounded in is the purpose of OPR in regulating professions on hold, the role of the Sunrise Report process, which is a really important part of our legislative mission and purpose. So I'll start with the sunrise assessment. I'm going to speak to you most because you have not heard the spiel. Everyone else on this committee is probably sick of the sunrise. You. Hope they're I they're not. I hope not, I actually find I'm listening

[Representative Robert Hooper]: to the occasional broadening their knowledge. I'm So sure of

[Lauren Hibbert, Deputy Secretary of State]: Chapter 57 is in Title 26, and it requires that we regulate a profession only if it's required to do so. So there has to be a risk of harm. And if we find harm, then we regulate. But there's another part of Chapter 57, which is our Sunrise Review scope review. And we added that section of the law sometime in I participated in it. I think it was in 'twenty and 'twenty one, pretty much directly as a result of that session's iteration of this discussion. And when we added that section, we had broad support from our professions, from the medical society, from the Department of Health. There was a lot of discussion about how somebody needs to do the due diligence to do the homework, the research, to help inform the legislature because you're not medical experts, because you don't have staff, because legislative counsel can't and really shouldn't provide an opinion about the scope expansions. And we've had so many scope expansions across the office. We've had a lot of new professions. We've regulated new professions, and we've talked a lot about the scope. So we've expanded the scope of APRNs. We've made them essentially independent providers in this state after some enhanced training. I think that's paid dividends for primary care. We have expanded the scope of dental hygienists. We've expanded the scope of many professions. And that's because with due diligence, with research, with understanding, and we have a robust sunset process where we have multiple public hearings, we get multiple comments, we look at other jurisdictions, We look at findings of liability, which is different than unprofessional conduct, which we also look at in other states. We try and get as much data as we can, and then we make a recommendation to this body. With optometrists specifically, we've done two sunrise reports, and this is a profession that's had their scope expanded previously. It used to be that they couldn't treat glaucoma and their scope was expanded. That was the first eyeball wars. We're in the second eyeball wars now. But the first eyeball conversation It's

[Chair Matthew Birong]: going to be a trilogy.

[Lauren Hibbert, Deputy Secretary of State]: We're in a trilogy. The second part is part one, part two, and part three, but yes, we're in a trilogy. And so this is a profession that scope has been expanded. Questions that have come up have been, why are the procedures so specific? The procedures are so specific, and you see that in professions where scope is expanding because it's how we keep control. And I just want to say, to your concern, Rep Stone, I think it's legitimate. That's why the procedures are really outlined in this bill. We wanted it to be constrained and clear. The other thing that is very different I think that was West Virginia, right? It was. Yeah. So the other thing that's really different between us and a lot of other states' regulatory boards is that the legislature very smartly put all of the professions, except for the medical practice board and AOE and plumbers and electricians, we can talk about that another day in my book. But you, your previous iteration, put all of the professional boards under OPR as an umbrella agency. And we are an independent state body that oversees all the professional activity in the spaces that we regulate. And that gives us active state supervision, which is really important if you had been sitting in this seat, and maybe some of you were.

[Vice Chair Lisa Hango]: I don't

[Lauren Hibbert, Deputy Secretary of State]: think any of you were. If you were sitting in a seat in 2017, you would have heard me talking a lot about this US Supreme Court case called North Carolina Dental. And that was North Carolina Dental Board was going rogue and issuing all sorts of anti trade, antitrust activity against teeth whitening, actually. And the Supreme Court said, you are expanding the scope of what you are responsible for and violating people. You're way outside, and you don't have state immunity because you aren't actively a state body. They were saying, don't sue us. We have state immunity. The teeth whiteners in the mall, we're suing them. And I'm being casual here, but it was

[Chair Matthew Birong]: It's good to find

[Lauren Hibbert, Deputy Secretary of State]: And the Supreme Court said, You don't have state immunity because you aren't actively supervised by the state. And so in order for boards to have state immunity and to have their actions sanctioned, they need to have active state supervision. So if you look at Title III, we added a ton of things that the director can say no to. The director can stop a board action. The director can stop rulemaking. The director can, and by extension, the secretary can avoid any policy. There's lots and lots of places where Jen, as our director, has authorization to say, No, the state of Vermont is not doing this. And it's because professional boards, and this is why I think scope expansions are so difficult, professional boards have an inherent personal interest in all of the conversations that come before you around scope. And the legislature before North Carolina Dental and then after North Carolina Dental even more solidified that OPR is independent, has active state supervision, and we can say no to the board of optometry, to the advisors of OT, to the nursing board. We oversee every single one of their actions, every minute of their rulemaking, every single piece of their legislative agenda. And that is by design so that someone who's not a profession is holding the line or advocating. Preston.

[Representative Mary-Katherine Stone]: So just to clarify, like in West Virginia, that's what happened is the circuit court, The board was sued in circuit court because the rulemaking board kind of overstepped their mouth. But you're saying that the board has rulemaking authority here, but somebody in your office oversees them to make sure that they are not just changing rules willy nilly on their own. It's still there's some kind of Well, there's multiple layers.

[Lauren Hibbert, Deputy Secretary of State]: How does the oversight work? So Emily Carr is our general counsel, and she has two attorneys underneath her. And that team does rulemaking. And they, every minute of rulemaking, make sure that they have statutory authority to assist boards in rulemaking. So that's the first step. Then Jen oversees their activity and looks to see if the statute has been exceeded. There's multiple, multiple steps. Then I look at every set of rules that's filed to make sure that we have not exceeded and help advise the secretary on whether to sign off on the rules. And then they're filed through ASARA and go to ICAR, which is the Interagency administrative rulemaking authority, and then ultimately, LCAR. So the LCAR, the legislative body, is the final sign off, and their primary objective is to make sure that the statutory authority is not exceeded, that the rules are This is the way I think of LCAR, I'm not at the legislature. But anytime that anybody, a board, an agency, is doing rulemaking, it's space that is yours. All of the landscape is legislative space, but you can't legislate down to the rule. You guys would have to be here full time all the time. And so you designate some of your responsibility to agencies, to boards, to do this really important work. But there's lots of checks and balances. And LCAR is your body that makes sure that what you've authorized through rulemaking has not been exceeded. Great. Thanks. And that is a structure that exists in a lot of states, but it's very robust.

[Chair Matthew Birong]: Grab Nugent.

[Lauren Hibbert, Deputy Secretary of State]: Also, can I just say one more thing? Absolutely. If you ever have questions about OPR's rulemaking or how we do it, or if we are in the midst of updating so many rules right now because we're finally policemen. And so if you ever have questions about it, please, or if your committee ever wants to know what is our process, maybe that would be a great beginning of next biennium conversation to have, because it is a fundamental function of the government and a fundamental function of OPR. The way that I always describe it to our professions, whether they're health care professions or not, is that statutes are the bones and the rules are the muscles that make the whole body go. We have to have both, but they are all one package, and we have to keep the rules in the statutory framework.

[Representative Robert Hooper]: Ben. Great analogy.

[Lauren Hibbert, Deputy Secretary of State]: It's tried and true. I'm on ten years now, and it's working.

[Chair Matthew Birong]: Thank

[Representative Kate Nugent]: you. I have two questions. One is just if you could reorient us in terms of where the rulemaking is and the process with this bill if this bill goes forward. Sounds like the beginning of that process you were just talking about?

[Lauren Hibbert, Deputy Secretary of State]: Yeah. Well, I think we haven't done any rulemaking on this topic, but I will let Emily I can hear that. My guess is that there will be very little rulemaking that needs to be done outside of the creation of this specialty, if there's any details around that, because this statute is so prescriptive. And that's another thing that OPR tries to do. If it's going to be very controversial, we think it should be in statute rather than in rulemaking because of exactly Rapstone's concern. We don't want to be expanding scope or doing something that's outside of what is our authority under the current statute. And scope expansion is something that is an expansion outside of our statutory framework, which is why you see things like in the OPR bill, the expansion of the pharmacy protocols for the new things that we're adding, COVID, strep, and flu, and you'll see the PrEP and the HIV prevention and prophylaxis

[Representative Kate Nugent]: in the Senate version that was added. When it comes back, you'll see that, and we support that. And the other part of my question is related to that too, is just if this change goes through, once it goes through, could you talk about the education that is provided to the practitioners and how they get that and how you make sure that everyone's on the same page? Because I don't know how many people read the bill necessarily, because they are interested in the topic.

[Emily Tarr, General Counsel, Office of Professional Regulation]: Well, there's a few ways. Operationally, we have a list of all licensees, and we can put out notices to allow them that the scope has been expanded and what the requirements will require. But also through our boards and also through the rulemaking process. So we asked for an extension of 2028 for this to go into effect to give us time to go through that rulemaking process, but also creating the new specialty. And that requires a lot of steps operationally within our systems. But the rule making process is minimum of eight months. And once this is passed, then we will start to amending our current rule because we already do have a rule for optometry. But to add these elements of this bill into our rule.

[Lauren Hibbert, Deputy Secretary of State]: And I just want to say on rulemaking, I should have said there's multiple steps, but there's a mandatory public hearing process as well. So the public will be notified. We'll notify all professions. The medical society will be there. We try and get as many stakeholders as possible. That's good. Do you want to talk anymore about what the scope expansion is doing? You've got that? You heard that. No questions. Perfect.

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: I mean, I think we're

[Chair Matthew Birong]: at the beginning stage of questions. Don't think this is not the end of the

[Lauren Hibbert, Deputy Secretary of State]: If you have additional questions after you hear from the variety of health care experts that you will hear from, we're happy to help. But these procedures are I'll just say really high level, these are the procedures that have been expanded in other states. The requirements to get this specialty will be the most stringent in the nation. We set the highest standard. There are many states who are allowing these procedures by optometrists at a lower educational standard. So we felt comfortable with the highest requirements. And we are joining a lot of other states, as you'll hear from pretty much every witness that you hear from.

[Emily Tarr, General Counsel, Office of Professional Regulation]: So that information also laid out in our written testimony that was included earlier.

[Chair Matthew Birong]: It is posted on today's page.

[Senator John Morley (Orleans District)]: Is that a yes?

[Representative Mary-Katherine Stone]: Yeah, just over. So opponents have said that the preceptorship requirements in comparison to other states is too stringent, but you're saying that you were fine with it being the way that it is now? You like it being like that? We like it to be where it is.

[Lauren Hibbert, Deputy Secretary of State]: Because we think that, and I understand why the optometrists would want it to be lower, but we think that training and expertise is really important. And having training with somebody to make sure that it's not only training in the classroom, it's also in the field. Lot of optometrists, part of our rationale is a lot of optometrists operate only with other optometrists, not in Many operate with ophthalmologists in the same center, but some operate more independently. We thought the preceptor given those factors.

[Senator John Morley (Orleans District)]: Thank you.

[Vice Chair Lisa Hango]: You're welcome. Thank you.

[Chair Matthew Birong]: Thank you for, wow, like what is this, a decade of service on this conversation? I love

[Lauren Hibbert, Deputy Secretary of State]: this topic.

[Chair Matthew Birong]: Okay, moving down the list, we're going to go over to lung participation. We're going to start with Doctor. Nate Leitheizer. Did I pronounce that correctly?

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: You did. Good morning. Hope you guys are doing well. Can you see me? Yes, sir. All right. So Leitheizer is difficult. So I'm known as Doctor. Nate at the College of Optometry, so much easier than Leitheizer. So good morning. I hope you guys are doing well. Am I able to share my screen?

[Chair Matthew Birong]: Charter committee is yes. He's nodding yes.

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: K. Let's see. Can you guys see my slides here? Can you see them?

[Chair Matthew Birong]: You are up and running, sir.

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: Okay. Again, good morning to the committee. I appreciate the opportunity to have, I was told ten to twelve minutes, ten to fifteen minutes or so. Is that correct?

[Chair Matthew Birong]: Works for us, but I don't have you on a clock, doc.

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: Okay, sounds good. Like I said, my name is Doctor. Nate Leitheizer. I am a faculty member and serve as Dean of the Oklahoma College of Optometry down here in Tahlequah, Oklahoma. I have been here for hard to believe seventeen years now. I'm a North Dakota boy born and raised. Did my four years of undergraduate work in North Dakota and four years of optometry school in Oregon, out at Pacific University College of Optometry in Oregon. And then I did my final training of residency in 02/2010 in Oklahoma where I was trained on the procedures that we are discussing today. The YAG capsulotomy SLT, basically a certain laser procedures and in office injections, eyelid procedures, things like that. So again, that's just a little bit about me. I have been fortunate to be traveling around the country, optometrists across The United States on laser procedures, injections. And I do lead the 32 laser and surgery course, which I'll talk more about here in just a little bit. So I've been doing laser procedures and surgical procedures in Oklahoma since 2009 and supervising students and residents since 2010 when I finished my residency as well. So you guys are aware there are currently 16 states that authorize optometrists to do laser procedures. Listed in front of you are the 16 states where optometry has been doing laser procedures. Oklahoma was the first state, actually it was the, 1988 was the first laser procedure done by an optometrist in the state of Oklahoma. So it's been since the late 1980s that in Oklahoma, optometry has been doing laser procedures. But you can certainly see the trend over the last fifteen years as an additional 15 states have joined Oklahoma in laser states. So optometry is continuing to evolve and modernize what we do as education has changed over the course of the last fifteen, twenty, twenty five years, and us helping our patients with these in office procedures. So those are the 16 states that currently authorize optometrists. Actually there's Kansas, Tennessee, I forgot to hit the button. Tennessee with state number 16 at the bottom there, so those are your 16 states. There's currently 22 states that authorize injections, eyelid procedures, as you can see here. So that's kind of the status of the number of states that are authorizing optometrists to do these in office procedures. Again, laser procedures, as well as injections into the eyelid, not the eyeball, the eyelid and eyelid procedures. So, how do you train on these? Again, I work at optometry school. I work with students and residents every single day. I'm in laser clinic on Mondays, yesterday, Tuesday, I was in optometry surgery clinic all day doing procedures. You receive training on these procedures. It's really like at four different levels. It's didactically in the classroom. Obviously you're gonna wanna sit through lectures and hear from experts, hear from faculty members, professors on these topics, dive deep into these topics, how they work, what you do preoperatively, what you do postoperatively. Here's the procedural technique. Let's watch a bunch of videos and you learn in the classroom. That's great first step. But then you gotta get practical hands on training in the laboratory on lasers and injections and how to do these procedures. These are hands on procedures. And again, this is a picture of our students and residents doing the actual hands on laboratory training. These are on model eyes as they're simulating an SLT glaucoma laser procedure. So doing these procedures to get the hands on laboratory training. These modal eyes are developed by an ophthalmologist, so developed by ophthalmology, and these are used by ophthalmology and all of the optometry schools as well to get that practical hands on training simulated procedures modelized. That's kind of the second step of training. Third step is let's test them on that. We test our students with written examinations and proficiency examinations, where they have a hands testing, where they have to go behind a laser with a professor that are going, okay, show me how you would do an SLT. What drops would you put in before? What drops would you put in after? Do the actual procedure on this model, So they are tested at both the written level and the proficiency level, hands on testing as well. And then in Oklahoma and in many other states, we are treating patients in clinic. Again, I'm in laser clinic on Monday, an OD surgery clinic, optometry surgery clinic on Tuesday with students, third year students, fourth year students, and residents doing procedures. That's your final level of training of doing this on actual patients under the supervision of an expert, an attending doctor. Those are your four different levels of training. And that is happening at all of the optometry schools. Level one, level two, level three is happening at every single optometry school. And level four in Oklahoma, in the states that allow this, are doing procedures on actual patients. And even in states, for example, let's take my alma mater, Pacific University in Oregon, where their law allows injections and the students get training on injections on actual patients. Their law doesn't allow lasers in Oklahoma, or excuse me, in Oregon. They bring in ophthalmologists that help to supervise these procedures so students can get training on that, even though the law doesn't allow that. Ophthalmology law allows that and they get training with preceptors. So a lot of optometry schools that are in states that doesn't allow that yet. For example, NECO in Boston, Worcester in Boston, SUNY in New York, where the law doesn't allow optometrists to be the attending doctor. A lot of these schools will bring in ophthalmologists to help supervise so these students can get experience in these procedures there. So here's some of our students doing laser procedures, as you can see here, again, doing these actual laser procedures, whether it's an SLT, whether it's a laser peripheral iridotomy, as you see here, or a YAG capsulotomy, doing these procedures on actual patients. Here's removing lesions. This is a picture from two weeks ago. Again, patients that have skin tags and little cysts and gross, benign growths on their eyelids, removing these eyelid lesions on the eyelids. That's what they're doing here. Getting trained with that fourth level of actual hands on experience with patients under the supervision of an attending doctor there.

[Chair Matthew Birong]: This is- Hold on one sec, doc. I got a hand up here from a member, Rep Stone.

[Representative Mary-Katherine Stone]: I So just wanna clarify for states where it hasn't been expanded, you were just performing these YAG procedures and so forth on models. And in the states where it has been expanded, in Oklahoma, you're doing this in person. Can you tell me, for example, in Oklahoma, how many hours of in person hands on training, not with a model that you are having your students complete?

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: You said not with a model, correct?

[Representative Mary-Katherine Stone]: Not with a model. And the states have expanded when you do have access to doing this in person, the Yagasuch on an actual person, how many hours of training are those students of,

[Lauren Hibbert, Deputy Secretary of State]: well, how

[Representative Mary-Katherine Stone]: many hours do they complete for their coursework?

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: Our students are in on average about forty to sixty hours of laser clinic and about thirty to fifty hours of OD surgery clinic. I mean, they're in dozens and dozens and dozens of hours of these clinics as they go through their curricular program. And that's not including the classroom. That's not including the lab. That's not including the testing. That is just specifically that fourth level of training on actual live patients.

[Representative Mary-Katherine Stone]: And that fourth, so forty to sixty hours, is that optional or is that included as a part of the coursework in those optometry schools? Like, is that something like a extra certification or is it something that all students have to go through?

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: That is required of all students at our school. I can't speak to other schools, but for our school where I'm in Oklahoma, that is allowed. And I want to be clear, dozens and dozens of hours, forty to sixty hours, that is in laser clinic only. That is not in glaucoma clinic, dry eye clinic, other ocular disease clinics. Our students get thousands of hours of clinical experience, but when laser clinic, where they're actually doing procedures, yeah, they are in forty, fifty, sixty hours of clinics.

[Vice Chair Lisa Hango]: Thank you.

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: You bet.

[Chair Matthew Birong]: Any other questions right now? We got a pause? Nope. All right. Back to you.

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: This is a photo of Doctor. Dan Phillips, a Vermont optometrist. He did his training with us last year. I've got to know Dan very well. This is him doing a YAG capsulotomy on a patient and he now practices in Vermont and will be helping patients in Vermont if and when this bill goes through. So there's a special picture for this one of Doctor. Dan Phillips who completed his training last year with us and just did a phenomenal job and carries all of these skills and this ability from his training down here in Oklahoma. And this is very similar to dental school. Dentists complete four years of undergraduate work and four years of dental school and dentists are performing all sorts of in office procedures after four years of dental. So they give injections in and around the mouth in their area of expertise, and again, do all sorts of these in office procedures. So they did not go to medical school. I know this because my sister's husband is a dentist that practices in North Dakota and did four years of undergraduate and four years of dental school. So very well qualified to do in office procedures. Dentists are after going to dental school, optometrists after going to optometry school, same thing. So again, there's no doubt in 2026 that optometry students are getting this training through those four levels as we just talked about. What happens if a doctor graduated twenty five years ago? Well, education continues. Education continues after you graduate. I graduated in 2009. If I practiced just with the knowledge that I had in 2009, I would be incredibly behind. We all would be incredibly behind. Education continues after graduation through CE or CME, continuing medical education. This is me doing a procedure, a YAG capsulotomy in a patient from a few years back. This is one of the main lasers that is done. This is a YAG laser and notice what this looks like. It looks like a slit lamp, That same microscope when you go to the optometrist and they look at your eyes and you put your chin in the chin rest and your forehead up against the forehead rest. My eyes are behind the oculars. My right hand is on a joystick there. We are focusing on the eyes. My point with this photo is the skills to do the laser procedures that are in question here that are being talked about in Vermont are the same skills as to do a slit lamp. I always tell optometrists when I travel across the country that you started training for lasers in year one of optometry school. Now you probably didn't realize it twenty years ago, but when you were developing these skills to focus in the angle of the eye and to focus behind the lens on what we call the posterior capsule, when you're evaluating that cloudy membrane, you were developing your skills for slit lamp to look at the eye and evaluate that, but you're also developing your skills for laser procedures because that's exactly what you do when you do these procedures. You bring your two beams together on that cloudy membrane and you hit a button on the top of that joystick. So 95 plus percent of the training you already have and we're going to add to that through this training course. Education continues after graduation just like all professions. I'll come back to that slide in just a little bit. This is the training course, the laser and surgical procedures course that maybe you've heard of the thirty two hour advanced procedures course. This is the course that has been used in all of those states that I showed you earlier, Kentucky and Louisiana and Arkansas and Mississippi and Colorado and South Dakota. I won't list them all, but this is the training course that has educated doctors that graduated ten years ago, fifteen years ago, twenty years ago, to help get that last level of training after they have graduated. Again, is the laser and surgical procedures course, a thirty two hour intensive course that has twenty two hours of didactic lecture and ten hours of hands on laboratory training. So this is the laser and surgery course. It has been the standard that has been used in every state that has passed legislation and successfully implemented those laser procedures and surgical procedures. Going back a slide, again, education continues. This is how that education continues. Just like for MDs, just like for DOs, what happens if an ophthalmologist graduated thirty years ago or forty years ago? They're not beholden to just what they knew then or the skills they have then, they add new procedures. If an ophthalmologist graduated in 1990, LASIK didn't exist in 1990. Certainly they are allowed to continue their education and develop their skills to add that new procedure post graduation. And optometry is doing the exact same thing, exact same thing here. I'm gonna pause. Any questions on postgraduate training and bringing doctors up to speed when they graduated five, ten, fifteen, twenty plus years ago.

[Chair Matthew Birong]: Rep Stone.

[Representative Mary-Katherine Stone]: So looking at the bill, you spoke a lot about the laser training that students were having the forty, sixty hours in person laser clinic. But I also just want to point out that the bill also authorizes corneal cross linking, eyelid laceration repair, lesion excision and biopsy types. And I was wondering if you could take us through that piece of education as That was also, if you were doing that kind of stuff in person and how many hours were dedicated to that type of training, if so.

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: At the student level or at the doctor level?

[Representative Mary-Katherine Stone]: At the student level.

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: So at the student level, was the thirty to fifty hours of our, what we call optometry surgery clinic. So they go through a course, a surgical procedures course. They go through that in their third year and fourth year. So didactically, they have that course, and laboratory training. And then clinically in Oklahoma, where our law allows that, they are going for, between thirty and fifty hours. That was the forty to sixty hours of laser procedures, clinical training, thirty to fifty hours of surgical procedures and injections training.

[Vice Chair Lisa Hango]: Okay, thank you.

[Chair Matthew Birong]: You bet. Are there any other questions on this pause? Rex, any goats?

[Vice Chair Lisa Hango]: Just wanna mention that we will or already have testimony from Doctor. Dan Phillips, who you mentioned was your student, and that should be posted to our webpage shortly if it isn't already.

[Chair Matthew Birong]: All right, back to you, sir.

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: Yeah, will, a couple of comments from this this course, the postgraduate doctor training course that we've done in in many, many, many states, you know, from one of the laser reps that works both with optometry and ophthalmology. This was a quote from us, the best SL training that I've ever seen. We did a course in The United Kingdom in December 2021, and an ophthalmologist there, comment. I was actually a little bit nervous about this. This is first time we've had an ophthalmologist there as you guys are becoming aware of the little bit of strife politically between optometry and ophthalmology during these eye battles, as I think you guys referenced earlier, this ophthalmologist said that I wish we had training this good when I started performing laser procedures. I was basically shown the laser during my first year of residency and said, go to it. This training was incredible. So these optometrists are incredibly well trained on these procedures there. So I wanted to comment a little bit on SLT. It is not the most common laser procedure done by optometrists in those 16 states. It is number two. YAG capsulotomy to clear a cloudy membrane after cataract surgery is number one. Okay, that's the number one. To me, the most needed laser procedure is SLT. It would be a huge public health win for the citizens of Vermont if optometrists had the ability to do SLT. Who treats glaucoma first line in Vermont and in all 50 states? And the answer is optometrists. Optometrists are the initial providers, the primary care providers. They handle the bulk of that. Certainly it gets to a certain level, then it goes on to ophthalmology for a variety of surgeries and very complex care in certain situations. But glaucoma, optometry treats glaucoma first line. And we now have two wonderful first line options for patients. It's eye drops and it's a wonderful laser called SLT. And patients struggle with compliance, putting in a drop every single day, twice a day, three times a day, they struggle with drop compliance. We have now been shown that SLT is a first line treatment option that has been proven with the light trial among many others. This is SLT not could be, but should be offered as a first line treatment for open angle glaucoma and elevated eye pressure supporting a change in clinical practice. This was released in 2019. This really has changed things in the last seven years. Instead of going to eye drops, eye drops, eye drops, eye drops for glaucoma, we now have a very gentle laser that should be done, should be considered first line therapy. And this helps ease the burden. Mrs. Jones or Mr. Jones doesn't have to take a drop or two every single day. We may be able to ease that on them, one drop less or two drops less by doing an in office procedure called an SLT. So this is, it should be offered as first line therapy. So to me it would be a huge public health win. The data showed that patients were more likely to progress on eye drops versus laser over six years. More eyes in the drop arm, the eye drop arm exhibited disease progression. That was twenty seven percent versus nineteen point five percent with SLT. So patients are more likely to progress in eye drops and you ask any eye doctor, why is that? And they say, because it's compliance. They struggle with getting that eye drop in every single day. So it would be a huge public health win if optometrists in Vermont were able to offer eye drops or SLT, one or the other, and make the decision together which is best for their patient there. So I'm gonna pause here. I'm gonna show a quick, this is a YAG Capsulotomy video you can watch. Any questions at this point?

[Representative Kate Nugent]: I'm not sure if this question is for you and or folks at APR, but I just want to feel like I understand better about what the dangers and risks are to potential misdiagnosis or if there's an incorrect diagnosis. The example that I have some familiarity with is a patient comes in and may have some cancer in their eye, and it looks like something else to an optometrist because of that training that you have. What processes are in place or could be in place or need to be in place to make sure that doesn't happen so that those diagnoses are correct and done in time?

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: I'm happy to answer that to the best that I can. And it really leads into this, when we look at patients that have these eyelid lesions, and it's already the optometrist job to decide when I look at this, when these patients come to my office, am I going to hold onto this and just say, you know, this is likely benign and the patient's okay with it and we'll just monitor it, or am I going to refer this out because I think it's cancerous? Optometrists are already making the decision. Let's put aside the actually doing the procedure. They are actually, they are already deciding, I'm gonna hold onto this because I think it's benign and we're just gonna observe, or I'm gonna refer this out for a biopsy and excision because I think it's suspicious. They're already doing that in all 50 states. Yes, only twenty two of them can they actually inject the lidocaine to numb it up and do the procedure, but it's already optometrists responsibility to look at it and make a decision, is this likely benign or is this likely cancerous? And they know they, and have all of the training to make that decision already. For example, you look at this lesion and you look, oh, this has been there for a number of years based on the features of this, this looks like potentially verruca, which is a viral papilloma. We're And gonna go ahead and remove that and there's the before and there's the after. So it's evaluating the features of that lesion. How long has it been there? Is there lash loss with this lesion? If they're losing eyelashes as part of a lesion, that means that lesion is destroying tissue and that's likely cancerous. What do the borders of the lesion look like? What do the colors of the lesion look like? What's the size? Again, many of these lesions are benign. Here's another one before, a little papilloma or skin tag and after. These are likely little seborrheic keratosis based on the appearance and the history and evaluating this. This patient wanted them removed. Let's say if they didn't, we could just observe this as well because these are likely not cancerous lesions and this patient was thrilled. Okay, here's another one, great big lesion. I referred this one out to ophthalmology because of how big this was. And our surgeon that I know removed this, had a great outcome, but I could have removed that, but I decided I didn't want to because of the size and the location of that. Chelazians or styes. Removing these Chelazians or styes. Here's another Chelazian that was the before and there's the after. Again, evaluating the appearance of this, how long it's been there. And I wanna show you a couple of pictures. The group from two weeks ago when I testified with the other committee didn't see this. These are pictures, this is from prior, but notice these patients, you ask any optometrist or any ophthalmologist, these lesions had been there for between seven and eight years, the patient was guesstimating. These are very, very likely benign lesions. I told the patient I was 99% certain that these lesions are benign. I never tell them a 100%. I always offer a biopsy because you never know for 100% certain if something is benign unless you get a biopsy. But I can be 99% sure clinically because they had been there for eight years based on the appearance, this was the before and that was the after. And this patient was thrilled to have these smaller benign lesions removed. Let me show you a couple of patients from yesterday. By the way, this is not from yesterday. This patient came in. I don't think we're removing that today. What do you guys think? That's going right to the specialist.

[Chair Matthew Birong]: That's a larger conversation.

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: Optometry will not be doing anything close to this. These are extreme examples. Is a patient from yesterday. I saw this patient at 01:30 yesterday afternoon in optometry surgery clinic. And the fourth year student came to me and said, Doctor. Nate, we've got a patient, she's very motivated to have this lesion removed. This is what might be a cyst on the side of the nose and that picture doesn't do justice, it's actually bigger than the picture kind of gives the appearance, but she wanted this gone. This was not there a year ago. And based on the size and the location, I'm an eye doctor, that's kind of the side of the nose. And I told her, I said, I really would like this in the hands of a dermatologist or an ENT because I'm not going to make this decision. Again, she was in my chair yesterday afternoon at 01:30, wanting me to do this. And I said, no. I said, because we have medical judgment. Optometrists have medical judgment to go, you know what? This is beyond our level of care. So, and this was another patient. Patient came in with a cyst. This was at 03:30 yesterday. And look at this cyst and see how it's kind of growing.

[Chair Matthew Birong]: You. Doc, I got another hand up representative stone.

[Representative Mary-Katherine Stone]: It's me. Sorry.

[Chair Matthew Birong]: Identify yourself.

[Representative Chea Waters Evans (Ranking Member)]: I'm an OT and

[Representative Mary-Katherine Stone]: I went to school under Mary Warren who's the founder of low vision OT. So I love this stuff but I was wondering if you could talk about the scope of biopsy authority and if that differs between states and if this bill addresses that because the agent's question was really good. And I just wanna know if you feel comfortable touching on that, if y'all are going to expand your practice, what kind of biopsy authority you have?

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: Was that question for me or for somebody else?

[Representative Mary-Katherine Stone]: It is for Like if you could speak to, you know, and your state in particular, and if you know if that differs state to state.

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: In our state, when you have injections authority to be able to inject anesthesia and do biopsies, you have biopsy authority as well. So yes, in Oklahoma, when we're looking at lesions and evaluating them, we have biopsy authority, the ability to do biopsies. Now there are different types of biopsies. We do what's called an incisional biopsy, which means we take just a little piece of the lesion to identify what it is. And if the lesion comes back cancerous, as the surgeon that trained me said, great, good for you, you uncovered a problem and now you send it off to ophthalmology because we have biopsy proven cancer, we'll send it to the specialist to do an excisional biopsy to remove the entire thing. Yes, do. Ahead.

[Representative Mary-Katherine Stone]: External biopsy only though, not internal. So the last slide that you showed, you couldn't have done a biopsy for that. That would have had to have been something done elsewhere, correct?

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: Correct.

[Vice Chair Lisa Hango]: Okay.

[Chair Matthew Birong]: Alright. We got a good lineup of witnesses still. What'd you

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: say I missed that? Sorry, you want more pictures?

[Chair Matthew Birong]: Is that

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: what you said?

[Chair Matthew Birong]: Yeah, yeah, yeah. No, totally.

[Vice Chair Lisa Hango]: Hi, that cyst on the eye, what's what happened?

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: That cyst on the eye saw at 03:30 yesterday, I referred that off to an ophthalmologist. Patient was 21 years old and it had been there for ten years. So I don't think it's likely cancer because as you cancer, you would think would grow over the course of ten years. But again, due to the nature of that kind of the plaque growth, again, he's in my chair for me to do it. And I said, Nope, I'm not gonna do that. I'm gonna send that off to ophthalmology. But that's the medical judgment that is trained in optometry school through our students, residents and clinical experience.

[Chair Matthew Birong]: All right. Well, we really appreciate your time and expertise. And if there's no other questions for this guest, I'm going to move into the bucket of other witnesses.

[Senator John Morley (Orleans District)]: All

[Chair Matthew Birong]: right, wonderful. Thank you very much, Choc.

[Senator John Morley (Orleans District)]: We'll let you

[Chair Matthew Birong]: know if we got anything else for you.

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: Thank you all. I will still stay in the call if you guys have any further questions. Thank you, thank you.

[Chair Matthew Birong]: All right, I will move on to next, Delaney Curran, ophthalmology resident and future Vermont ophthalmologist. How you doing?

[Dr. Delaney Curran, Ophthalmology Resident]: Hi, how are you guys? Thanks for

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: having me.

[Chair Matthew Birong]: Good, yeah, of course. So table is yours. Share your thoughts and perspective.

[Dr. Delaney Curran, Ophthalmology Resident]: Great. So yes, I'm Delaney Curran. I'm the chief resident currently at the University of Massachusetts in Worcester in the ophthalmology department there. I have a four year bachelor's degree in biology and then my medical degree, both from the University of Vermont. And I am doing my four year residency now in ophthalmology, but will be returning to UVM to be a comprehensive ophthalmologist in September. It is my privilege to be able to return to the state of Vermont with the skills now to help the community after everything they did for me for eight years. But I feel compelled to testify today in opposition to this act as written out of my desire to advocate for the patients of Vermont. I have worked with several skilled and talented optometrists at the University of Massachusetts. They're excellent assets to the team. They take excellent care of the patients in Massachusetts. And so I do not want to undervalue in any way their role, but I have been very freshly exposed to the very steep learning curve for the surgeries that are being proposed as additions to optometrists scope. And I'd like to share with you my experiences with what is involved in learning both the technical skills and also some of the softer, less clearly defined skills required to do these types of surgeries safely and effectively for our patients. The first and probably most obvious requirement to be a surgeon is to be technically capable of performing the steps of the surgical procedure start to finish. For ophthalmologists, there is a national council called the Accreditation Council for Graduate Medical Education, called the ACGME, who holds all the residency programs in the country and their residents accountable to meeting certain standards prior to graduating residents to operate independently. There is a list of surgeries that we are required to meet minimum case numbers for as primary surgeons under the supervision of board certified attending ophthalmologists. Will mention that the minimum numbers required of us are more rigorous than those that it appeared are required by the optometrists for the course in this proposed act. Additionally, these minimum numbers do not tell the whole story of the extent of our supervision and training, Often prior to being allowed to even attempt to do a surgery as primary surgeon, there are months in which the supervising physician will only let you as the resident practice a couple of the easier steps and slowly add more of those steps until you grow proficient. And then eventually you're able to do a case start to finish. And at that point, can start to count the cases towards your minimum case numbers. Because of this, it can take many repetitions with many different patients before you even begin to count things. For example, as a resident, I have done 18 gag lasers as the primary surgeon start to finish. Our minimum is five, but I have done the steps of 40 in order to gain the proper proficiency before I started being able to do full cases start to finish. This is all for patient safety, with the attending always present to step in if there is difficulty or a complication, able to give you as a learner the tips on how to do things better and ensure you're not accidentally acquiring bad habits. The reason for this steep learning curve with all of these eye procedures is that the eye is really small and filled with important and really tiny fragile structures, such that being even a fraction of a millimeter in the wrong space can have consequences for the patient long term. That yag laser video you saw, it's true focusing is step one, but firing the laser in the correct plane is step two. And if you are less than a millimeter off, you can do something called pit the lens, which causes a white opacity, which can damage the lens permanently and affect their vision. Even after mastering the standard procedure as well, throughout my three years of ophthalmology residency, I also experienced the more challenging variations of the procedure. Cases where there's unexpected bleeding, uncooperative patients who are moving while you're trying to do the laser procedure, and sometimes the scar tissue around the area is really dense and it's more challenging to do than just a routine case. And in those moments as a resident, you are still being supervised, even if you've already met your minimum requirement. The true test of confidence comes at this point after you were taught how to adjust from your standard procedure to adapt to these trickier patient scenarios. What is worrisome to me is that in this current act, in the category of optometrists who are already optometrists, maybe from twenty years ago, their requirement is to do this surgical procedure on two patients, two repetitions before being signed off as independent. I don't know of a single ophthalmology resident who would have felt comfortable operating independently with two repetitions of any of the surgeries being proposed in this act. An additional layer to this is that the ACGME gave these minimum number recommendations with the assumption that every ophthalmologist and resident has already had a fundamental base knowledge in the principles of surgery. So as a medical student, some of you probably know this already, but I will just review, the first two years are lectures with exams. The second two are hands on rotations. These rotations are sixty to eighty hours a week. Every medical doctor is required to do rotations through core specialties, surgery, internal medicine, family medicine, OBGYN, pediatrics, psychiatry, emergency medicine. And then after that, medical students do many other hands on electives that cater to their interests. So if you like surgery, you do many more surgery rotations. This is followed up by your intern year, which is your first year as a doctor. And often for ophthalmologists, this requires rotating through all sorts of specialties acting as something called the first call provider. I will speak for myself when I say that I rotated through neurology, the ICU, emergency medicine, plastic surgery, general surgery, trauma surgery, anesthesia, and others as well. This means that before even becoming an ophthalmology resident, we have already had three years of hands on experience clinically and I believe those are essential to being a good surgeon. The first time that I did an eyelid laceration repair was as a first year ophthalmology resident. Eyelid lacerations are often more difficult to repair than lacerations elsewhere on the body due to their small size, location really close to other delicate structures, and the importance of that eyelid continuing to function to protect the eyeball underneath it. However, going into my first eyelid laceration repair, I had already performed dozens of lacerations on other parts of the body. So considerations such as how to prevent infection and clean the wound, how to anesthetize the area with lidocaine, how to pull the skin together to prevent scarring, how to maintain proper tension, and how to select the right type and size of suture are all things that were learned with repetition over three years on rotations in the emergency room, family medicine, surgery, OBGYN rotations. So when it was finally time for me to suture an eyelid laceration for the first time, I still had a lot to learn about the specifics related to the eyelid anatomy, but the rest of the skills were already ingrained, routine, straightforward for me. And this is true of all the surgeries and lasers in question today in this act. There is a foundation to them that was learned by me in medical school and intern year that made the ophthalmology specifics much easier to absorb and learn. Speaking of that thirty two hour course, it also has an eight hour mandated hands on time, and again, I mentioned that all of these things look like they're two repetitions of each type of surgery. If I had been set free independently at this stage of my learning curve, which is the equivalent of three or four days as an ophthalmology resident by the hours, I would have not been ready to practice safely. For me, I required many more repetitions with supervision to become proficient with these skills, even with a strong background that medical school provides. And now I'm going to pivot and discuss some of the softer skills of surgical training, are much more difficult to measure, but maybe even more important than being able to do the steps of surgery. First, evaluating a patient before surgery and deciding whether to do surgery or not is nuanced and is one of the last things I learned to do independently in my residency. Concepts such as, should we stop their blood thinner medication? Can they even lay flat for the surgical procedure without experiencing respiratory distress? Is their diabetes well controlled enough for them to heal appropriately? Is that stye actually skin cancer? And is that eyelid laceration suspicious for involving the tear drainage system, which would require a completely different method to close? And is the vision actually going to improve with that yag laser? Or was there actually a complication from their cataract surgery that needs to be addressed, maybe with a second type of cataract surgery, not the yag laser? These are all incredibly important things to consider before signing people up for surgery. Many of these things are taught in medical school and intern year before ophthalmology residency starts. And then many of these other things are taught during the three years of ophthalmology residency, where every day we are exposed to these conversations and decision making all with guidance from our mentors over three years. Additionally, a safe and good surgeon is trained in how to manage their own complications. This is a skill that is sometimes harder than the actual surgical procedure and takes months of years managing patients post operatively. A straightforward example is that sometimes eyelid laceration repairs can become infected after they are sutured. Medical doctors such as ophthalmologists are trained in the signs of infection everywhere, the feet, the lungs, the bloodstream, the brain, and the eyes. This means our pattern recognition is well attuned to the early signs of infection. We have experience medically to help us know when the infection is severe. When is someone showing signs of sepsis? That's a bloodstream infection. When to send them to the emergency room for labs? When do they need cultures? When do they need strong IV antibiotics? What class of antibiotics should you prescribe to target the correct bacteria? Do they need a CT scan? Are we worried that maybe this infection has spread to their brain or their orbit? If you do enough surgical procedures, you will get complications such as infection, bleeding, damage to other structures. But being able to catch these things quickly and act appropriately is what makes you a good surgeon and is something gained with proper experience and supervision over time. And finally, as a young ophthalmologist, I can tell you that my colleagues in training currently are watching closely to see what you decide before they make their decision about where to set up practice as an ophthalmologist. Knowing that a state supports optometrists doing surgery independently after maybe a forty hour course is unattractive to ophthalmologists who have spent so many years, so many hours of their life in training specifically to do these procedures. I worry that, you know, if the hope is to increase the community's access to quality eye care with this bill that perhaps the opposite may occur. I appreciate you all taking the time to hear my testimony today. I hope my message has been made clear, which is that learning eye surgery is not simple and there can be dire consequences if done incorrectly. I had years of dedicated hands on experience from board certified ophthalmologists, well as surgeons and doctors and all specialties in order to feel comfortable safely performing these surgeries, and I hope any doctor being granted this responsibility and privilege has held the similar standards in the state of Vermont. Thank you. Do you have questions?

[Chair Matthew Birong]: Yeah, any questions for our witness?

[Senator John Morley (Orleans District)]: I

[Representative Robert Hooper]: think I heard you saying that your colleagues are watching closely to determine where to open practices. Did I catch that? Yes. Any idea of how many that would be, if you're willing to share that?

[Dr. Delaney Curran, Ophthalmology Resident]: I'm only speaking for mine at my residency who I've talked to you about their future plans. There's only six of us, it's a small residency. I will say that my colleague, there's only two of us graduating this year, my colleague who's going to go into cornea is not interested in practicing anywhere where this bill has been passed. He's explicitly said that to me. I think in general, people especially who want to go into perhaps private practice, there's some concerns about how it affects their referral base. And most of us are in a lot of debt from school and we need to have some financial guarantee that we're going to be okay, and I think it is a little bit more risky financially to be doing something like opening a practice in states where there's also the competition from optometrists.

[Chair Matthew Birong]: Any other questions for this guest? Thank you so much for your time.

[Dr. Delaney Curran, Ophthalmology Resident]: Thank you. Appreciate it.

[Jen Kirby, Office of Legislative Counsel]: And

[Chair Matthew Birong]: next, I'm going to go to Alicia Faiss. Am I pronouncing it correctly?

[Dr. Alicia Faiss, President, Association of Schools and Colleges of Optometry]: Close. It's Faiss, but that's okay. Respond to So many different thank you so much, you guys, for your time. I also want to thank the previous speakers, and I think Delaney spoke very eloquently about a lot of different aspects, and hopefully I can also lend some expertise as Doctor. Lighthizer did, and he and I share some similarities. So just to give you guys a little background on me. So my name is Doctor. Alicia Feis, and I am the current president of the Associated Schools and College of Optometry. So as the president, I am aware of many of the things that are happening all across the country. I'm also the dean at the Arizona College of Optometry, which is at Midwestern University. It's an interdisciplinary graduate medical campus. I'm also a practicing optometrist. I do pediatrics. So luckily a lot of the procedures that you're talking about I don't personally do, but I practice in Arizona. And so I can tell you a little bit about what that education and training looks like since we do not currently have those particular procedures. As a reminder, all the schools and colleges of optometry similar to what Delaney talked about, were all accredited by our ACOE. And so not only do we have to provide particular education to all students, but we also have to guarantee that all students have met certain types of encounters, had various experiences, and also within the classroom setting that Doctor. Lighthizer discussed, they have to meet certain criteria within midterms and practicals before they can even move forward into the curriculum and become a graduate of the medical school. At Midwestern, I'm very fortunate of all of the individuals I get to practice with many of the programs we have identified in the professional degree program that has just been identified. We do have OT here, so I know that there's an OT there. I love working. I specialize in vision therapy, so I do a lot with OT as well, but I'm very familiar with dental medicine. We also work very closely with the medical school. And then we have two full time medical doctors that are actually a part of our optometry faculty curriculum. And I think a lot of that speaks to the education that actually happens within the optometry school. So when I often compare the medical school versus the optometry school curriculum, Delaney discussed that there is a lot within the medical school curriculum that they hear about. But again, many of that's diverse in its training. Where truly optometry is focused in on four years specific to the eye, but also any systemic disease or anything surrounding the eye, anything that affects vasculature because there are so many blood vessels in the eye. We really are experts, almost like a cardiologist in relationship to a medical doctor. Yes, they can do several different things. We are primary care people for the eyeball, but we also know very much about the eye. And so when I see, and we often have many medical students or interest in ophthalmology, we're often the ones that are teaching them about what it is they should be doing, what it is that they should be looking at just because there are differences in just how the structure of the education happens. So, optometry school used to be focused much more on glasses and contacts. And I can tell you that that is still a part of our curriculum, but it is not anywhere near what it used to be several, several years ago. And many of the students also pursue a one year residency afterwards on top of the four years of school. And so within the basic sciences, our students, particularly at my school and I know at all the other schools in College of Optometry, we do have basic science clinical foundations. So the concern of, would the patient have sepsis? Is their diabetes well controlled? Those are all things the students are not only tested on in the classroom setting, but they also have hands on experience within the clinical setting. My students in particular actually rotate through our diabetes clinic with our multi specialty clinic. And so not only do they see it from what it looks like from an optometry student and from an optometry clinic, but then they also get to see what that looks like from the medical perspective. We get several two years of training in ocular disease, two years of specialized training within the eye. And then of course, two years of patient care under supervision in many different settings. They're at a VA setting, they're at an Indian Health Service. Again, volume disease clinics where they're able to train. And then beyond that, there are actually three sets of national boards that we take within optometry in order to become a licensed optometrist. And all of those are in various settings. Are all in applied basic sciences to ensure that systemically should anything go wrong, that we are very well comprehensively looking at a patient, not only then honing in on ocular aspects and then as well as the patient skills aspects. So not only during school are we tested on their proficiencies and their skills. And I appreciate during some of the components of the bill, it's only these two procedures. Those are actually at the culmination of their training. And so we're trusted at a national board level. Unlike medical boards, there actually is a national board that is overseeing these technical skills and ensuring that we're all meeting a national standard. And so when we think about the scope of clinical management, I did wanna talk about, I know there was a question about injections and corneal cross linking. I will tell you injections have been taught in optometry school. They actually practice on their classmates, again, on the lids, usually the second time that they actually learn it. And I will tell you, every single student gets up and does that. That is all through a classroom training before they are able to do it. We go over all of the safety things that they need to consider. When would you ever want to do these procedures? And then talk about all of the complications. There's extensive education in medications to prescribe, when you shouldn't prescribe, when you should prefer, when this should go out, but then also there are continued laboratory examinations, even examinations within their clinical training to ensure that everybody's skills are staying at the level that they're supposed to. And then of course, the continuing education once you graduate that you have to continue to stay up within your skills. So, lasers was not taught when I graduated school. I actually went through the course that Doctor. Lighthizer taught. All of our faculty have gone through all of those courses. And so even though in Arizona, we cannot perform these particular procedures, all of my faculty have been trained on them so that we can also know what is being discussed and happening in certain states where we don't have those particular procedures. I thought I would also highlight at my particular school where the medical school is taught and in the osteopathic curriculum, there actually are only four and a half hours delivered in eye specifically in the four years of medical school training at the osteopathic medical school. And actually the optometry faculty teach three of those four and a half hours. The other one and a half hours are actually taught by AI simulations. So they go in and perform the skills. And so everything from the didactic knowledge that they are learning is actually taught to them by the optometry faculty. And within our particular clinic and many of the other clinics across several states, optometrists are actually the ones that are currently managing the pre and post operative complications when it comes to the ophthalmology procedures. And I know Delaney had talked a little bit about concerns of where to go practice and am I going to be able to pay off my student loans. I'll tell you from someone who has worked in several practices, also is the dean of an eye institute, I can tell you, as you look at reimbursements, the type of procedures that we're talking about here are not ones that are going to be paying off your ophthalmology student loans, where surgeons actually want to practice. And when I look at the various, we have several ophthalmology practices in the Phoenix area. And I will tell you most of them wanna be in the surgical procedures and wanting to do cataract surgery and all of the invasive procedures that they spend much more time on. My husband is actually a practicing optometrist at a very busy ophthalmology, optometry practice. And several of the ophthalmologists say that they would actually prefer the optometrist to do that because they don't wanna spend the time in the minor surgical procedures because it's not where they spent the time in their training. So just kind of to give you a little bit of a practice setting versus a training difference. Also, one of the reasons that there's been a big jump in the scope of expansion in 2019 was when there was standardized language that all surgical procedures needed to be taught at all schools in College of Optometry. So every single school teaches to the highest scope because of course we want all of our students to be able to practice wherever they come from and to be able to go back to practices that have that in from an optometry perspective. There are several more optometrists that are coming into the field. And I will tell you, they are looking to practice for places that they can teach to the highest scope. I've actually practiced in California, Colorado, Illinois, Arizona. And it was interesting as I moved from one state to the other, I was allowed to do something in one state in Illinois, and then I moved to Arizona and I wasn't allowed to do it. And it wasn't that my knowledge base had decreased, it was just that's where the scope of expansion was. And so there are actually less individuals moving into the profession of ophthalmology. So it is something for us to consider being able to take care of the patients. Looking at the curriculum itself, I wanna stress that Doctor. Lighthizer is exactly correct. There are several classroom procedures that happen and something that we've discussed a lot with our ophthalmologist. He often talks about how optometry is very conservative in their training. They spend a lot of time in the classroom. They provide all of these midterms and then they allow the students to practice whether that's an eye model or whether that's on their classmates before they ever let them touch a patient. Where in medical scroll training, a lot of it is observation and watching someone else perform the procedure. And then often they jump in and actually practice as even Delaney talked about on the easier patients. Our students actually are trained. They have to prove that they can do it on easier patient. They have to go through an assessment. If they don't reach a certain percentage, they have to go back and practice until they finally reach that training. If they don't ultimately reach the training that is required within the curriculum, then they actually can't move forward and do the things that are being asked of them. Just as an example, what a checklist might look like, is this the right patient? What are the communications that we're having? Is this the right procedure? Are we aware? Do they have the right anatomy, pathophysiology? Does someone have diabetes? What are the techniques that I have to do based upon the anatomy within the particular patient? What are the use of topical or periocular agents? Meaning, are there any allergies to medications? Is there anything that I should be thinking about thinking about the type of bacteria? What are the complications? If there is complications, how do I perform that? What is the specific documentation or referral criteria? When should or shouldn't perform this procedure? All of those things are discussed not only in the classroom and the didactic learning, but then those practice in the laboratory, they're practice in a simulation lab, they're assessed both in the classroom and the laboratory, and then they're observed in clinic. And then they're able to be able to work a little bit. And then of course, moving towards the number of hours that they see within the clinic. So very similarly, that is for every single type of procedure that we perform in optometry. That's not unique to laser and surgical procedures. So when Doctor. Leitheizer talked about the slit lamp exam, our students learn examination in their first year of optometry school. So by the time that they would even be at practice, that's actually five years of training that they've practiced these skills, where if you look at ophthalmology, it's actually only three years. So our particular skill development and motor development with many of these skills is actually often has many more hours of practice than within ophthalmology. It's just in a very different way. We in Arizona cannot actually perform it. So all of our students actually work under our ophthalmologists within our training. Then we also have students who go to states such as Kentucky or Oklahoma. And so as ASCO, we ensure that all the students are having the particular observations or are rotating through states if it isn't offered in the particular state where they're going to school, and also ensuring that they're building the clinical reasoning skills to be able to perform those procedures. In addition, the bill talks about going to the National Board Examination. So not only in our curriculum are we teaching this, but they have to actually pass the national board examination going through all the particular procedures that you see here. And so they must meet a minimum standard according to a national set standard, as well as the surgical section. So not only are they learning in the classroom, performing that in a clinic, but then there's a national standard that they have to take. And so if you think about the safeguards, because I think every doctor of optometry and every doctor honestly seeing any patient always takes an oath to protect patients and we take that very seriously. So when I take a look at this bill, I do think that there are many safeguards in place in order to ensure that the safety of patients is the primary concern. There are credentials, there's national examinations to get there, there's supervised training. Those preceptorships would not sign off if they didn't think that they were capable of performing the procedure. And so then they would be doing perhaps more procedures in order to demonstrate that. And there are patient safety measures putting in place in order to limit the procedures because they're often low risk. We're not asking for invasive procedures that lead to several surgical complications that we leave that to our surgical ophthalmology guidance because that is truly where a lot of their training comes from. And then this also allows access to care for patients. Some of them don't feel comfortable. Often many people will go to their optometrist first because they see that as their first line, just like a primary care versus going to an ophthalmologist. And many of the ophthalmologists aren't necessarily in maybe particular locations. We often find that many optometrists actually see We're often people that many people come to because we need to be able to see. And so we will be sometimes those primary care providers. And so we can actually make those decisions to send them to ophthalmology if needed. So hopefully-

[Chair Matthew Birong]: Hold on one second. I had a hand up. Yeah. There you go.

[Dr. Alicia Faiss, President, Association of Schools and Colleges of Optometry]: That's actually the end. So we can stop there.

[Chair Matthew Birong]: Oh, all right, cool.

[Vice Chair Lisa Hango]: Thank I just wanted to confirm something that I thought I heard you say. Doctor. Leithweiser earlier mentioned that he could not speak to what other schools are doing. But I believe I heard you say that if a school is located in a state that doesn't allow these practices, the students are given the opportunity to go to other states for clinical rotations, so they can practice these And everyone across the board now in The US is getting a similar education at elementary schools. Is that correct?

[Dr. Alicia Faiss, President, Association of Schools and Colleges of Optometry]: You are correct. And that is correct.

[Vice Chair Lisa Hango]: Thank you very much.

[Chair Matthew Birong]: Anything else for this guest? Ripstone?

[Representative Mary-Katherine Stone]: I got a follow-up to that. I just wonder, is it a requirement to graduate from any program in The US to have hands on experience with those procedures, not just using models, but doing hands on or would it be optional? Like what Rupango said is that there's an option to do a fieldwork or whatever the correct terminology is for your profession in another state where it is licensed, but is it a requirement? And is it something that's tested on your board examination?

[Dr. Alicia Faiss, President, Association of Schools and Colleges of Optometry]: So great question. No, it is not a requirement at all the schools, unfortunately, because of the way accreditation works, we can't require it because legally, if we were doing it in our state, then we would be violating our law, so we can't make it a requirement. But I will tell you that many of the students seek rotation sites in states that allow the particular procedures. And so I'm not aware of the number of percentages of students across all of the colleges. But to answer your question, it is optional and not necessarily required, but many of the students, all of them practice on the models, but whether they've had the extensive training that Doctor. Lighthizer's students have had. That's not the case. However, in order for them to pass the licensing examination, all of the students I know of, or even the licensed practitioners that I'm aware of that have graduated from school, they go and observe and or work with many of the optometry students and or optometrists that can practice in that way. That's actually how they gain the hands on experience in order to pass the licensure examination before they could even move the way that the bill S-sixty four is written. Hopefully that helps clarify that

[Representative Mary-Katherine Stone]: for you. Yep, thank you.

[Vice Chair Lisa Hango]: Okay. Uh-huh.

[Chair Matthew Birong]: All right, anything else before we move on to the next one? Seeing no hands. Thank you so much for your time. And we're going to move next to Amy Barto. How are you?

[Dr. Amy Barto, Optometrist (Louisiana)]: Hello, hello, Chairman. Hello, committee. I think I'll be I don't know if I'm your last speaker still or not, but I'm hoping I'll be able to be someone that can really apply some reality to practical practice relationships when it comes to what S-sixty four provides. I am a clinician who practices in Covington, Louisiana, just forty five minutes north of New Orleans in an area that borders rural Mississippi. And so I see patients oftentimes from an hour to two hours away who don't want to go into the city for their medical eye care. Louisiana uniquely passed its scope modernization law in 2014. I came to Louisiana in 2015 not originally from the state, but just as Doctor. Feist had mentioned as someone who wanted to gain an additional level of skill in ocular disease and primary care. And having just passed their scope expansion bill, I found myself in a unique opportunity to practice in Louisiana. Since then, and like I said, I hope to be a little bit of a reality, I have now practicing for eleven years doing all of the surgical procedures described in S64. And it's something that I'm very proud to be able to share, you know, is part of my daily care and routine with patients. Our patients love coming in to see the eye doctor and knowing that the person who provides them their traditional comprehensive annual care can also provide them their medical care when needed. And it's something that I really hold to a high esteem to continue to provide responsible medical eye care in that regard. Again, I've been doing this for eleven years. I graduated in 2015. I was looking for a state that would allow me to use the clinical training I had received from 2011 to 2015 in optometry school. And so when I look at a bill like S-sixty four and I look what Vermont is trying to do, I realize just how much of a difference there is between my experience and my colleagues in Vermont and those who are graduating today who have so much more clinical education than I had just a decade ago. So I would love to take questions because I'm sure you all want to talk to someone who is doing this day in and day out. Can really explain. One of the things that I always like to bring about is the conversation as was brought up today in regards to competition or taking away from our ophthalmology colleagues. And I can tell you, am a testament that just does not exist in Louisiana. This is not a conversation that is had outside of these testimony spaces, outside of these bill readings and outside of this law experience. In fact, everything goes back to us taking care of our patients because at the end of the day, patients are first. In fact, this year, Louisiana has a bill on the docket and guess who one of our biggest cosigners is? It's our ophthalmology colleagues who have signed We on as well with are teaming together for patient access and care. So again, when I hear what we're hearing today, and I know this committee and the Vermont legislature has to weigh the pros and cons, but when it comes to patient access and care, you can be assured the students today who have graduated today have the skills to perform these procedures. They have the medical understanding, they've gained that knowledge. The doctors that you have currently in Vermont have also acquired that knowledge and they're going to be through S-sixty four re equipped with additional knowledge if they need any refresher courses. But again, I had my surgical clinic this morning and I'm glad to be on the call today, but I was doing the procedures you all saw videos of. I have to make determinations for my patients what's their best of care. And if I am not the responsible medical provider to do it, prefer the patient to another. And when we build a relationship like I'm proud of Louisiana, we have one of the highest standards of eye care in the nation. Healthcare we're working on, but eye care I am so proud of because here in Louisiana we take responsibility for patients, care and health and access. And again, I'm a testament eleven years out. I used to be the young doc, now I'm a mid career professional. But again when I hear the conversations that are had again I'm eleven years experience of doing everything that's talked about in S-sixty four. It's a reality and it's a good thing for Vermont.

[Chair Matthew Birong]: All right, questions? Was that a hand wrap?

[Senator John Morley (Orleans District)]: Hango, yes.

[Vice Chair Lisa Hango]: Yeah, it's not really a question, just a comment that I feel like I'm really happy that we've heard from a lot of witnesses from rural states. We've heard from Oklahoma, Louisiana. We've heard some commentary about West Virginia, and they're all very similar states to Vermont in that they're really rural. And I guess your point about patients who don't want to go into the city and you're located so that they can access you and your services without having to travel great distances to a city applies to Vermont. I'm really happy that we've been able to hear from other rural states and how they've made this work. Because in my opinion, we have a severe shortage of both ophthalmologists and optometrists. So it is helpful to hear about other states that are forming partnerships between the two specialties and knowing that one does not preclude the other. Think that's very important to keep in mind. So, you.

[Dr. Amy Barto, Optometrist (Louisiana)]: Thank you. And I just want to reiterate one really important facet is just because we may be closer to patients doesn't mean that our quality or standard of care is any less than. Again, we uphold the highest standard of medical eye care. And so, when patients see us, they're guaranteed that high level of care just closer to home with their neighborhood provider.

[Chair Matthew Birong]: Great. Any other questions for this guest before we move on to

[Senator John Morley (Orleans District)]: the next?

[Representative Mary-Katherine Stone]: I was just wondering, one of the arguments is that by expanding the scope that malpractice also increases in your field, and I was

[Dr. Amy Barto, Optometrist (Louisiana)]: just wondering if you could speak to your experience in Louisiana if that has been true or not? That has not been true. And if there has been any increase over the past eleven years, it's been extremely nominal. And I'm very proud to say that as someone that we were talking about student loans, as someone with those student loans, the last thing you want is an additional malpractice, but we want to protect ourselves too. In Louisiana, we have something unique. I don't know if Vermont does. We have a patient compensation fund that all medical providers put money into for any additional exposure and risk that may occur, even that has not gone up. So, that actually increases our annual kind of cost, but those numbers have not gone up at all. And again, we have medical parity. So, if we do this procedure or an ophthalmologist does this procedure, we're all paid the same because we're all providing the same level and high standard of care for this procedure. And that's what is understood by our medical insurance providers too. So, to answer your question, no, there's not been any increase. And if it has been, it's been extremely nominal and not been anything that has priced anybody out of their care.

[Representative Mary-Katherine Stone]: We don't have that fun, but maybe we should. So thanks for that idea.

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: Do you guys allow prior witnesses to comment on a question or not?

[Chair Matthew Birong]: Yes. We do. Oh.

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: Yes, sir. I will go into that question hot off the presses. Is this study, which can you guys see my screen? Mhmm. Malpractice payments by optometrists in The United States and analysis from '96 to 2023. This was published April 27. So it was published last week.

[Jen Kirby, Office of Legislative Counsel]: I have

[Vice Chair Lisa Hango]: it on my computer. Right?

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: And you can and I'm happy to send this to the committee. Malpractice and payments involving optometrists remain infrequent, very modest, with most claims arising from diagnostic rather than procedural issues. There's no evidence that expanding optometric privileges, lasers, injections has increased malpractice risk.

[Vice Chair Lisa Hango]: Thank you.

[Chair Matthew Birong]: All right. Any other questions or commentary for the two guests as they appear on the screen right now before we move on to the next witness? Seeing no hands, thank you both. So we are going to stay with Zoom with Doctor. Jessica McNally.

[Representative Robert Hooper]: Okay.

[Representative Mary-Katherine Stone]: She will be joining just as soon as she can.

[Chair Matthew Birong]: All right, great. We'll go over

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: there to Jeff Young. No, I just had that done

[Chair Matthew Birong]: as Zoom for an 11:30 on my sheet here. So we will pivot over to Doctor. Young. How are you doing? Oh yeah, chair is yours.

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: A hot seat.

[Chair Matthew Birong]: Once you're getting put in

[Senator John Morley (Orleans District)]: the chair. What's up?

[Chair Matthew Birong]: Said, once you're getting put in the chair.

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: Morning. Nice to be here. I was fortunate that I had some time today. I'm a comprehensive ophthalmologist. I practice just a few miles up the road here in Berlin, and I've been here for the past thirteen years. Let me start here. Sorry.

[Representative Robert Hooper]: That was quick.

[Vice Chair Lisa Hango]: Yeah. Please explain to us what a comprehensive ophthalmologist is.

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: Question. So a comprehensive ophthalmologist is someone who does general ophthalmology, meaning that we generally take care of things like cataract surgery, YAG lasers, SLT, all the all procedures that are taken care of here is something that a comprehensive ophthalmologist would do. We see patients for general eye care, like for diabetes and anything they might have a problem with. We're on call at the hospitals seeing any emergencies that may come in. Any problems that anybody would have would generally come to me first.

[Vice Chair Lisa Hango]: Okay, thank you. So you don't specialize in some.

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: I don't do retina or things like that. No, no, no. Yeah. So I do. A little of everything, something that that is maybe fewer and far between in a lot of places, but certainly in Vermont, we have several

[Chair Matthew Birong]: comprehensive ophthalmologists. Yeah. Okay.

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: So an optometrist, an ophthalmologist, an optician, I mean, sounds like the intro to a good joke, but it's not. Those are it's something that is confusing for almost everyone. Even educated people cannot distinguish between these three different related occupations. My own father-in-law, who is highly educated, generally very detail oriented. He even observed my years of medical school and residency and is still confused which of these professionals performed his cataract surgery, which measured his refraction and which fit his glasses. Passage of this bill will only further confuse this. I've given I've been given the opportunity to share some recent and real experiences from around the state given to me by ophthalmology colleagues that give me pause when considering this legislation and the wisdom in passing this legislation. The stories, all of which affected real Vermonters, will illustrate the effect that inadequate training and misjudged confidence can have on real patients. I also want to mention that we have received similar examples from Kentucky and Oklahoma, which you will receive by email, which have been submitted to the committee. And these are accounts of ophthalmologists that speak to the fact that just because there may be no reported outcomes by the boards of optometry, that does not mean that there have not been bad outcomes, and that there have not been any complications with these procedures. If a state board of optometry says that there has never been any reported bad outcomes or a single complication, I think we should all be skeptical. Naturally, all professionals, including optometrists and ophthalmologists, can make mistakes which result in bad outcomes. The difference is that the following examples will illustrate that inadequate training is often the primary cause of these reoccurring and undocumented bad outcomes. I'm not here to say that optometrists are better than or worse than ophthalmologists or to say that they are not concerned with patient safety. But to just show that comprehensive surgical training, as my colleague and my former medical student, Delaney Curran, so eloquently said that dealing with simple as well as very complex cases in surgical training is necessary to develop the proper surgical skill and the careful surgical judgment that is necessary for these procedures. Some of the cases are alarming because the optometrist in the situation mentioned to the patient that they would be performing these procedures in a year and that they could just wait until then, as if the passage of this legislation was a foregone conclusion even months ago. These are recent accounts from real Vermonters. My first story. An optometrist who was a recent graduate from an optometry school referred a patient to an ophthalmologist for evaluation of narrow angles and which is a condition that can cause dangerously elevated pressures in the eye and result in vision loss. The treatment for narrow angles is a laser procedure called a laser peripheral iridotomy. I think you guys have had some education on those. It is a laser surgery that is requested in this bill. Upon examining the patient, the ophthalmologist found that the patient had already had this procedure performed at some time in the past, and it was clearly visible on the examination. The patient was sent back to their optometrist without having an unnecessary laser procedure. This case is concerning because the optometrist had apparently been trained in these procedures as stated by previous witnesses, And the modern optometry curriculum should have prepared this this optometrist to identify this person that this patient had had this procedure performed previously. As a result, the patient was sent for an unnecessary evaluation, which costs both the patient and the system precious time and money. Now, second case. An optometrist referred a patient to an ophthalmologist specifically for a glaucoma laser procedure. The patient reported that their optometrist described the laser as simple and easy, and that optometrists are fully trained to perform this laser, and that it should soon be available in Vermont without referral to an ophthalmologist. The laser referral was made by the optometrist's office as a routine and non urgent consultation. Approximately one month out, the ophthalmologist reviewed the incoming referral within twenty four hours and suspected a more severe condition requiring urgent evaluation and asked the patient to come in the same day. The evaluation revealed that the patient had been misdiagnosed and was not a candidate for the referred laser. In fact, use of this laser would have worsened the underlying condition and would likely have resulted in permanent vision loss. The proper diagnosis was made and the patient was treated appropriately. This story is another example of a misdiagnosis and an inappropriate treatment plan that could have resulted in an unnecessary procedure. The request for a non urgent referral also put the patient at risk for vision loss.

[Representative Robert Hooper]: Let me see.

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: And from some of the prior optometry, my prior optometry colleagues who have testified on this, they sometimes make it seem as though a laser procedure or the ability to do a laser procedure is going to solve almost every problem we have with medical care and delivery of eye care in Vermont. And I'll tell you right now that it will not. Laser procedures are very, very small portion of of what is necessary to take care of that. A third story, an optometrist referred a patient to an ophthalmologist for a YAG capsulotomy, which you've all heard about. Although the patient did have mild posterior capsular pacification behind both of the artificial lenses, the patient had no visual complaints, no blurred vision with glasses and no glare. Despite her lack of complaints, she had been referred for this laser surgery. The ophthalmologist felt that proceeding with the ag capsulotomy in this situation necessity was contraindicated and did not perform the laser. Furthermore, the ophthalmologist found that the patient's only complaint about her was about her dry eye, which was not being treated adequately and can also cause decreased vision. The ophthalmologist felt that withholding an unnecessary surgery and avoiding exposing the patient to undue risk was the most appropriate. This patient was referred for a laser surgery, which was not medically necessary. Her main complaints were attributable to dry eyes and laser surgery would not have been helpful. This case shows that surgical judgment matters, especially knowing when not to do a surgery. Proper training, careful listening, critical judgment are all essential in surgical decision making. The best way to protect patients control health care costs is making sure that only patients who truly need a procedure receive it. And now a fourth and final story, an ophthalmologist received an urgent referral by an optometrist for a patient who had come to that optometrist for eye redness and vision loss. The optometrist noted high eye pressure and believed the patient to have narrow angles, which I mentioned a condition which I mentioned earlier, which is a condition that can cause blindness and vision loss. The optometrist diagnosis for this patient was angle closure glaucoma, and the recommendation was to perform a laser peripheral iridotomy. The ophthalmologist's exam showed that the patient's narrows were in fact, their angles were in fact not narrow, but were in fact wide open. And the ophthalmologist noted instead inflammation inside the eye. The ophthalmologist did not perform a laser peripheral iridotomy and instead proceeded to investigate the cause of the inflammation. The results revealed that the patient actually had tuberculosis, which is a rare and serious infectious disease that is life threatening. In this story, the optometrists made an incorrect diagnosis in which performing the laser would have, A, not improved the pressure or open the angle, and B, would have worsened the underlying inflammation, since laser surgery always causes inflammation, and C, would have greatly confused the entire situation. What was needed in this case was identification of the eye inflammation and a search for the cause, which in this case was blood work and a chest x-ray. What makes this case even more concerning is that the referring optometrist had, the exact same week, published an essay in a prominent Vermont News publication in which they assured lawmakers that optometrists have proper training and skill to make advanced medical and surgical decision for care of the eyes. The optometrist's own actions demonstrated that they had significant gaps in expertise and would have harmed the patient and the public. In this case, this diagnosis of tuberculosis, which is a deadly infectious disease, must be reported to the state and would have been missed and an unnecessary laser surgery would have been performed. In each of these cases, the patient was referred for a laser surgery, which if it had been performed, have at very least been medically unnecessary and a waste of time and money, and at worst resulted in blindness. I've only taken a few minutes here, and I've chosen only a few cases. You'll receive, I think, we've provided additional cases of similar situations from all around Vermont that demonstrate the same kind of scenarios. And these cases demonstrate that proper surgical skill and more importantly, careful surgical judgment requires comprehensive training, not cursory courses. It requires graded and guided surgical experience, not just fulfilling a checklist. It requires time not measured in the tens of hours, but in the hundreds of hours dealing with complexity and complications. Thank you.

[Chair Matthew Birong]: Thank you very much, Doctor. Questions from the witness? Perhaps I'm

[Representative Kate Nugent]: going give

[Chair Matthew Birong]: you an easy pass for

[Representative Robert Hooper]: the rest

[Lauren Hibbert, Deputy Secretary of State]: of the call. No,

[Vice Chair Lisa Hango]: no, no,

[Senator John Morley (Orleans District)]: no. No apology either.

[Representative Mary-Katherine Stone]: So given that this current standard of care already requires optometrists to know when they're at the limit of what they can and cannot do, do you see the bill, this bill that we're talking about changing that fundamental ethical and legal obligation? Because what I'm hearing now, it sounds like these are just really bad optometrists, regardless of this bill is on the table or not, and they shouldn't be doing what they're trying to do now.

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: No, yeah, so I'll say one thing. I don't think these were bad optometrists. I'll say that, first

[Senator John Morley (Orleans District)]: of all.

[Representative Mary-Katherine Stone]: Well, were practiced.

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: I think if they would have had the surgical privileges, they could have made a very bad decision based on what they did. And so sometimes the thing that I would think about about this situation is sometimes you don't know what you don't know. Right. So if you there are studies you can look at in in, say, general surgery literature where they say that sometimes the people who feel most confident in procedures are the people who actually know the least and are least competent in those procedures, where if you ask a first year general surgery resident if they can perform an appendectomy perfect, they might say yes, where a fourth year general surgery resident might say, Yeah, I don't know. There's so many things that could go wrong. So sometimes in your zeal to do procedures and to fulfill these things that you feel trained to do, sometimes you might make a poor decision. And that's where I think the the problems come in in these situations.

[Representative Mary-Katherine Stone]: Thank you.

[Chair Matthew Birong]: Any else for the witness? No. Thank you so kindly for the short notice. Juggling in the schedule, sir. It's appreciated. And with that same sentiment, Doctor. McNally, good to see you again.

[Dr. Jessica McNally, President, Vermont Ophthalmological Society]: Good to see you too. How's everyone doing today?

[Chair Matthew Birong]: Not bad, not bad. It's been an immersive morning.

[Dr. Jessica McNally, President, Vermont Ophthalmological Society]: I'll bet. I saw there were a lot of things on the schedule for you guys.

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: Yeah.

[Dr. Jessica McNally, President, Vermont Ophthalmological Society]: Well, thanks, of course, for allowing us to participate this morning. Just for the record and for any committee members who have not met me, I did speak in front of this committee a couple of years ago. Chair Byring and I have spoken about this issue, but my name is Jessica McNally and I'm an ophthalmologist and current president of the Vermont Ophthalmological Society and a member of the Vermont Medical Society. Again, thank you for allowing me to testify on behalf of Vermont ophthalmologists to voice our concerns about S-sixty four, which, as you know, is a bill that would expand the scope of practice of Vermont optometrists to include eye surgery. I just wanna be clear to everyone with everything that you're gonna be hearing, because obviously there are strong feelings on either side of this, that our singular goal as Vermont ophthalmologists is to ensure that Vermonters receive safe, high quality surgical care here. With that in mind, we of course have some grave concerns about this bill and its implications. In the close to twenty years I've been in practice, I have seen firsthand the confusion about the difference between an ophthalmologist and an optometrist. Just a few weeks ago, I was referred a patient who was diagnosed with a disease that can cause rapid blindness over the course of one day. This patient did not receive timely and appropriate referral because the PCP and likely the patient themselves thought the patient had been seen by an ophthalmologist. The lapse in time between the suspected diagnosis and the appropriate referral may have serious consequences for the patient in the coming years. Just two days ago, I was at a middle school sports event for my kids and I found myself explaining to one of the other moms that she sees an optometrist in Burlington and not an ophthalmologist. And again, having to explain the differences between the two, and this was an extremely educated person who just didn't know the difference, and we encountered this all the time. We know that there was a 2018 survey that was done by the American Medical Association that found that over half of the respondents either did not know or were not sure if an optometrist was a physician. And this is important because in other committee testimony, has been brought up, well, even if optometrists are given these privileges, you don't have to go see an optometrist in order to have these surgeries done. That's true, but you have to have the wherewithal to know what the difference is between an optometrist and an ophthalmologist to make that decision, and it's very clear in my career and I think the careers of anybody involved in Eyes that patients, legislators, lobbyists do not know the difference between an ophthalmologist and an optometrist until they're educated about it. All ophthalmologists are physicians and surgeons. Ophthalmologists complete a four year undergraduate bachelor's degree program, as you've heard, after which they complete four years of medical school, identical to all other physicians and surgeons. After completing medical school, of course, you know that we go on to obtain four to six more years of residency and fellowship training. That first year of residency incorporates inpatient and outpatient care, and as you've heard, this includes general surgery, internal medicine, emergency medicine, and critical care. Then residents complete three more years, and this is focused training on advanced medical eye disease and surgery of the eye. And that's where the differences really are between optometry and ophthalmology. Ophthalmologists have the surgical training that is centered towards the eye, whereas optometrists do not. The three year ophthalmology residency is standardized in all programs across the country and must meet rigorous National Accreditation Council for Graduate Medical Education Requirements, ACGME, as you heard earlier. Many ophthalmology trainees follow-up their residencies with another one to two year fellowship in a subspecialty such as cornea, retina, or glaucoma, thus giving them even more surgical experience and totaling hundreds of cases. As in all surgical residencies, ophthalmologists are held to the highest standard and do not graduate from their program until they have proven competency, not simply by numbers, although we know that that's truly, truly important. We know that the more times you do something, the better you get at it, or from passing board examinations. So testing in a simulated environment does not mean competency. Competency comes from meticulous formal assessments by our mentors. They look at elements such as working cohesively with our colleagues, professionalism, patient relationships, and surgical skills and progression, of course. Each member of residency program clinical competency committees, and there are such committees in each residency program for ophthalmology, each member has to agree that a resident has attained competency before that resident is allowed to actually graduate and be considered an independent practicing position. Optometrists complete a four year undergraduate bachelor's degree program, as you know, and then attend a four year optometric program. They then have the option of completing additional training, but this is not required. And the materials provided by optometry and OPR second report examples are given of such additional training as low vision, contact lenses and ocular disease. The materials that were given to OPR also describe education, including lectures, videos, and laboratory simulations of surgeries on model eyes and model skin. However, in the numerous curricula supply, the standardization of training across optometric training programs is not clear. What is clear is that the far majority of optometry schools, there is no hands on surgical training on live human beings. In fact, out of the 25 optometry schools in the Association of Schools and Colleges of Optometry, only three schools in three states, Kentucky, Indiana, and Oklahoma, are able to teach all of the surgeries that are in S-sixty four on live human beings. None of the other optometry schools can teach all of these procedures. We have observed that the system of licensing optometrists to perform advanced procedures is starting to develop cracks. Recently, was revealed that Kentucky allowed 21 optometrists to be licensed without passing all of their required exams. A malpractice lawsuit has in fact been filed against one of those optometrists relating to use of a laser incorrectly. A West Virginia court also recently determined that their board of optometry overstepped its bounds and they voided a rule that allowed optometrists to perform eyelid surgery The two main arguments, of course, that Vermont optometrists have continually brought forward over the years since beginning their effort to expand scope access or expand their scope has a course men access and costs, which is what you're hearing. Optometrists in Vermont have repeatedly asserted that by allowing scope expansion, access, quote, will be improved. I've been participating and listening to testimony and hearing from legislators on this now for a number of years, and I've gotten to the point, especially this session where I'm not even sure what is being referred to when we talk to access, when we talk about access, whether it's access to general eye care, which is what optometrists have testified that they supply routine eye care or whether or not we're talking about access to these surgeries. We seem to be discussing access, but those are two very different things. Access to routine eye care and access to these surgeries is totally, totally different. In Vermont, we are extremely fortunate in that we have enough ophthalmologists to provide all medically necessary scalpel and laser surgical care in, on, and around the eye. It has been suggested in previous testimony that absolute numbers of ophthalmologists in Vermont does not reflect access because some of us subspecialize and don't perform these surgeries. The fact is that there are only a handful of ophthalmologists that don't perform any of them, and that's retina specialists. A July 2023 article published in the Journal of the American Medical Association, in fact, showed that in Oklahoma, Kentucky, Louisiana, Arkansas, and Missouri, all states that had an increased scope to include laser surgeries did not lead to a shorter travel time or improved access. There was a more recent November 2025 article that was published in the Journal of the American Medical Association that demonstrated that although there has been a decrease in the number of ophthalmologists, we are actually practicing in a greater number of locations, thus providing services. The article further determined that nationwide driving distances to optometrists and ophthalmologists is similar. We have approximately 33 practicing ophthalmologists in the state, Not every county has an ophthalmologist and that's true, but not every county has a urologist or a dermatologist or a neurosurgeon either. These are highly specialized physicians and surgeons, and expecting to have a provider with that level of training in all counties is completely unrealistic. I think we can all agree that we would not feel comfortable with a family practice doc, providing urological surgeries to fill any urology gaps. This is no different. As we again have heard from optometry numerous times in testimony, they provide primary eye care. Our concern as ophthalmologists and for our patients is that access to the primary eye care needs of Vermont are not being met. All diabetics, for example, need yearly eye exams, dilated exams, all contact lens wearers need yearly exams. I recommend that everyone over the age of 50 get yearly eye exams. It is extremely difficult for us to understand how the workload of an overly busy optometrist already overwhelmed with providing primary eye care would be any help by providing these surgeries. The surgeries would overwhelm that already overwhelmed optometrist. And we also know that many optometrists in the state of Vermont have ceased taking a lot of vision insurances. So patients are still going to have to travel for their routine eye care no matter where they live or work. And then if you look at OPR's reports from 2020 and 2023, even they couldn't prove that expanding the optometric scope of practice would improve patient access to care. At that time in both reports, they were unable to show that. I can absolutely assure the committee that if a patient in Vermont needs expedited or urgent eye surgery, our optometrists who we work with know that they can contact us. Many of us have each other's cell phones, email addresses, and these patients can be taken care of immediately. With regards to cost, there have been many arguments put forward by optometry, insisting that scope expansion will decrease cost. And when they say cost, I'm assuming that they're referring to general cost of medicine. One argument that they have made is that patients could simply be brought into another room on the same day of diagnosis and have that scalpel or laser surgery done right then and there. Optometrists argue that this would decrease costs by saving patients a trip or a few trips to see a surgeon for another evaluation and for postoperative care. This argument just to simply not hold water. All ophthalmologists can cite examples as Doctor. Young just did of patients who were sent to them for the requested surgeries in S-sixty 4 that after being evaluated, those surgeries were deemed unnecessary or even ill advised or dangerous. Other patients who we see opt not to move forward with surgery after they hear about all the different risks that are possible. And this in fact decreases costs by avoiding a surgery. Furthermore, it's nearly impossible to take a patient on the day of diagnosis and perform the surgery because you have to get prior authorizations first and reimbursement is very complicated. Optometrists had made the argument that increasing scope will make Vermont more attractive to young graduates. We heard this in front of the House Health Committee. There is no evidence in other states that optometrists are flocking to those states who have increased scope. I've explained that the laser equipment that is required to perform these surgeries can cost anywhere from 40 to $60,000 The instrumentation that is required for doing surgeries on and around the eye requires expensive sterilizing equipment that you have to keep in your office. Any eyelid lesions that are removed have to be analyzed by a hospital pathologist. So anything removed has to be sent to pathology. And based on OPR's website, if you actually look at the numbers, there are new optometrists coming to Vermont. We've got about 30 new licenses that were granted since 2021, and this is with scope not increased in Vermont. It seems that it would be completely irresponsible to use this promise of scope expansion to entice optometrists when we know that they are already not appropriately trained to do the surgeries in S64. Expanding optometric scope of practice to include surgery will not lower cost. The cost for medical services is set by a payment formula created by Medicare, not by traditional supply and demand as it might be in other businesses. Each procedure and service has a code and a set payment. In 1986, federal law established that optometrists would be reimbursed for services by the Centers for Medicare and Medicaid Services, CMS, at the same rate as ophthalmologists. Private insurers use the same set of codes and their payments are similar to those established by Medicare. Private insurers also reimburse ophthalmologists and optometrists the same amount. The topic of facility fees has come up in the past in testimony in front of other committees. It has been suggested that we are charging facility fees as ophthalmologists, and that is causing the costs of these surgeries and medical care to go up higher. But these fees are generally applied to hospital based surgeries and not the office based surgeries that are being requested in S-sixty four. Therefore, optometrists performing these surgeries in their offices are not going to be saving any money because there is already no facility fee being charged. In fact, the 2023 report from OPR stated, OPR is unable to determine whether scope expansion would have impact on costs. Optometrists have repeatedly portrayed ophthalmic lasers as being safe and easy. The Vermont Ophthalmological Society strenuously rejects this characterization. Ophthalmic lasers, as mentioned by Doctor. Young and as proposed for use inside the eye are categorically surgical instruments used for altering tissue. Surgical treatment with ophthalmic lasers is not a primary eye care service. Furthermore, as Doctor. Young mentioned, the existing and future laser eye care needs of our monitors do not come close to providing the caseload numbers needed for optometrists to maintain competency. I reviewed my own laser surgery data from my practice from September to November 2025, before I testified to the Senate and submitted it for their review, and it demonstrates relatively extremely low numbers of lasers performed compared to the number of referrals that we actually get from local optometrists and optometric practices. Optometry scope expansion into the scalpel and injection surgeries listed in S-sixty four would allow optometrists to remove lesions, what some refer to as lumps and bumps when they're talking to legislators. And this would be on the eyelids and around the eye. And the current legislation states without characteristics or obvious signs of malignancy. These chair sides have been described in other testimony by optometrists as being chair side procedures. I can assure you that these surgeries are not chair side, they are performed under sterile conditions with specialized lighting and equipment. The oculoplastic specialist at UVM, Doctor. Libby Houle has spoken and written at length about how difficult it is to predict a malignant from a non malignant lesion, no matter how many pictures you've looked at and how that even she, an expert, has been surprised with biopsy result. I myself experienced this about two months ago when I took off a lesion from an eyelid of a 35 year old woman who was a completely benign looking lesion. I sent it for pathology as we always do, and it came back a basal cell carcinoma, complete surprise. Doctor. Young had a very similar experience a few weeks ago where he took a lesion off of someone that looked like it was completely benign and again, came back with a diagnosis of malignancy. And that is why we send all of our pathology specimens to the hospitals for pathology review. There are also technical changes in removing lesions from around the eyelids, which for example, is what happens to the skin after the removal. These are things that we can't show you legislators unless you're sitting beside us in our surgery suite so that you can see what happens. The resulting wound, for example, is often much larger than expected than the actual lesion when it's cut off. The lesion can look very small, but the wound is very large. There can be excessive bleeding that can be anxiety provoking to the surgeon and the awake patient. A surgeon may think that they're taking off the lesion that's not going to need surgical suturing repair, and then all of a sudden it does, and you might not be expecting that as the surgeon. S64 would allow repair of traumatic eyelid laceration. Traumatic eyelid lacerations are something that are seen in a hospital based setting. Repair of even superficial eyelid lacerations can be extremely complex and is much more difficult than suturing a surgical incision. Not only that, but S64 doesn't even require any minimum number of lid laceration repairs to demonstrate competency. It's not even in there for as a minimum competency number. Other proposed surgeries in the bill include corneal cross linking, which is a surgery used to stabilize the surface of the eye called the cornea from certain degenerations. There's only one ophthalmologist in the entire state of Vermont who is trained to perform the surgery. And that is because he is a fellowship trained cornea specialist. This surgery is outside the scope of every other ophthalmologist in this state. It costs thousands of dollars and is most often performed on a very particular subset of patients who are younger, usually than 30, and sometimes even teenagers. S64, again, requires no minimum number of corneal cross linking surgeries to demonstrate competency for optometry. Our retina surgeons continue to have significant concerns about the inclusion of this thing called fluorescein angiography in the bell. This is a dye test that looks at structures of the eye in the back of the eye. The dye is actually injected into a vein in the arm and can cause nausea and sometimes vomiting and potential anaphylaxis, which is reaction to an allergic reaction that can cause death. Although that's very rare and optometrists will tell you that, but our retina specialists maintain that the far majority of retina disease can be diagnosed with other equipment that they already have in their offices. It's widely available and the far majority of optometrists in the state of Vermont already have machines that can give you the same results as a dye related fluorescein angiography test. I don't do dye fluorescein angiography tests, the only ones who do that in the state of Vermont are the retina doctors, and even they are doing it very infrequently. S64 requires no minimum number of fluorescein angiograms to demonstrate competency either. We know and we tell our patients that anytime a needle or laser is used around, on, or in the eye, there is a risk of blindness. And the optometrists tell you this as well. But we think it's imperative for you all to understand what these surgeries are in order to make educated decisions about S-sixty four. Now, again, we can't bring you into the our surgical suites to show you what these are, and we're limited in time. So there are videos that I would love to be able to show you that I can't today, but I will give you a brief description and hopefully we'll be able to submit some photographs to you all about what these are. One of the requested lasers, for example, this laser trabeculoplasty is a laser surgery that is used to purposely cause damage to the microscopic drainage system of the eye in order to lower the eye pressure. There are risks to this surgery that Doctor. Young likely mentioned, including inflammation, elevations in eye pressure after the surgery, swelling in the back of the eye of the retina, and swelling in the front of the eye on the cornea. Posterior capsulotomy is another surgical procedure that is put in this bell. This is another laser surgery that is used to clear away a film that can develop after cataract surgery on the artificial lens implant that is placed. This develops because a few cells from the cataract are always left behind and they proliferate over time, but the film often does not affect the vision. So many patients who have had cataract surgery do not need to have this laser, even if they do have some amount of a film that has formed. The risk to this can include inflammation, elevations in eye pressure after the surgery, displacement of the artificial lens, swelling of the retina, retinal tears and retinal detachments, and also permanent marks on the lens implants that we call pitting, which if those pits occur in the wrong location can cause loss of vision. Peripheral iridotomies are lasers that create holes in the iris, which is the colored part of the eye. And those are done when the drainage system is in danger of closing. This is rarely necessarily and more and more unnecessary to be done. And it's also extremely difficult to perform in an emergency situation. That is the type of situation where optometrists usually will tell legislators that is the most important for them to know how to do this particular laser procedure, but it requires the most skill and the most practice in a setting like that, because it is extremely difficult to see the iris in a setting of an emergency to do the peripheral iridotomy. Risperipheral iridotomies include inflammation, elevations in eye pressure after the surgery, bleeding inside the eye and damage to the lens beside the iris. Again, for myself, I probably perform two laser peripheral iridotomies as prophylaxis to prevent emergencies. Maybe once a year, I'll have one patient who needs these lasers done. Certainly not enough to maintain competency for an optometrist who has not had appropriate training for this. Chelazions are lumps on the eyelids that consist of collections of inflammatory cells due to blocked oil glands. Sometimes these are treated with intralesional injections, which typically means a steroid. This steroid can cause loss of skin pigmentation. Any kind of injection on the eyelid, including the steroid, can cause stroke of the optic nerve. It can also cause perforation of the eyeball and blindness because you're using a needle. Risks of excision of a chalazin include stroke of the optic nerve as well, also due to injections around the eyeball and perforation of the eyeball and blindness. There's also mention of inclusion of subconjunctival injections in this legislation that would be an injection on the eyeball itself, which could also cause perforation and blindness. And then there are various lesions of the eyelid and adnexa, which are structures around the eyeball, which include bleeding infection, again, perforation of the eyeball blindness, unexpected need for suturing, and some of the issues that I mentioned before. Basically, OPR's recent report creates a training program for eye surgery, which they label a preceptorship. S-sixty four incorporates some of that model but with even less stringent requirements. With all due respect to OPR and to our Vermont legislators, including you all, we assert that setting appropriate standards for medical and surgical training should only be done by a properly accredited organization. This organization should be comprised of individuals with firsthand knowledge and expertise in eye surgery and developing curricula with proven standardization to ensure competency of surgeons and accountability of the accrediting body. Safe eye surgery for Vermonters can only be provided by physicians who have completed medical school and an ACGME accredited ophthalmology residency program. And just to clarify, I wanna make sure that all of the legislators understand that when we talk about the board examinations that optometrists perform in order to become certified and to gain competency for doing these surgeries, they are all based on model eyes and simulated situations. There are no board exams that will show a real person having these procedures done to show competency for optometrists. Vermont legislators are not alone in navigating the issue of optometric scope expansion into surgery. Within the last few weeks, the governor of New Hampshire vetoed a bill even less expansive than S-sixty four and legislation in Maine failed. Understanding eye surgery and the training it entails is extremely difficult. And we understand that, and we understand why this bill is so difficult for you. I will close with where I began, that the singular goal of the Vermont Ophthalmological Society is to ensure that Vermonters receive safe, high quality surgical eye care. As legislators, your ultimate responsibility is to protect the safety and well-being of the people of Vermont. That includes yourselves, that includes myself, it includes all of our families, your constituents, and I hope you will keep all that in mind as you move through this process of learning about s sixty four and what it might mean to all of us. Thank you very much. Yeah.

[Chair Matthew Birong]: No. Thank you very much. And representative Hango, then I got representative Stone.

[Vice Chair Lisa Hango]: Thank you. I just have one clarifying question. I'd like you to repeat what you said about the board exams showing real results on real patients. Could you repeat that sentence, please?

[Dr. Jessica McNally, President, Vermont Ophthalmological Society]: Sure, so the board exams, if you read the bill, the last couple of pages of the bill where OPR made recommendations about the board exams for optometrists, that they wanna seek advanced licensure, there's a three part practical or a two to three part practical exam that they have to perform involving demonstrating their ability to perform injections and simulating lasers. And those are all done on simulated eyes and simulated skin that is nothing like normal skin and is very poorly representative of what doing one of these lasers would actually be like in a real life situation. Thank you.

[Chair Matthew Birong]: Repzone.

[Representative Mary-Katherine Stone]: Last question. I just know that Title IV in federal law requires any issues of malpractice to be reported to the in PDB. So just hearing a lot of the concerns that you and the former witness raised. Would you agree that if that is happening in Vermont that we should see a corresponding spike in that data that's released by that entity just so that we know where to look at to match up these anecdotal stories with the actual data.

[Dr. Jessica McNally, President, Vermont Ophthalmological Society]: In terms of if you're looking for malpractice data for-

[Representative Mary-Katherine Stone]: For these stories that we're hearing about optometrists in particular, providing procedures that result in blindness or in harm or even potential harm. I know that that is what I've been told is that, you know, under federal law that we are mandated to report those instances to that entity.

[Representative Chea Waters Evans (Ranking Member)]: So are these ophthalmology

[Dr. Jessica McNally, President, Vermont Ophthalmological Society]: malpractice suits that you're looking to look at in

[Jen Kirby, Office of Legislative Counsel]: the state of Vermont?

[Representative Mary-Katherine Stone]: Optometry to back up some of the testimony that we just heard from you and the previous witness about things that are happening in Vermont. Those should be reported to Oh,

[Dr. Jessica McNally, President, Vermont Ophthalmological Society]: I see what you're saying.

[Representative Mary-Katherine Stone]: So So are you seeing that data correlate with the anecdotal stories that you are hearing? So

[Dr. Jessica McNally, President, Vermont Ophthalmological Society]: you're wondering if the stories that Doctor. Young reported qualify as malpractice?

[Vice Chair Lisa Hango]: Yes, correct.

[Representative Chea Waters Evans (Ranking Member)]: Is that

[Dr. Jessica McNally, President, Vermont Ophthalmological Society]: what you're asking?

[Representative Mary-Katherine Stone]: Correct, because from my understanding, if they do, then we should be seeing a spike in the data that is you know,

[Representative Chea Waters Evans (Ranking Member)]: that entity.

[Dr. Jessica McNally, President, Vermont Ophthalmological Society]: I see what you're saying. So I think malpractice suits are very, very difficult to tack down primarily. They are brought forward by patients. So patients need to have the wherewithal to know that something bad has happened to them. And I believe in all of the anecdotal stories that we have shared with you all, there have been no blinding outcomes of any of these patients. So there have likely been no malpractice suits from such stories in Vermont versus in Kentucky where the laser was done incorrectly on the patient by an optometrist and the patient did lose vision, there has been a malpractice suit on that because there was a dangerous visually threatening outcome. So I don't believe you're going to see any malpractice suits associated with the stories that we're telling. These are anecdotal stories. We understand that they are also representative of the kinds of issues that we deal with on a weekly basis and the probably worst stories that we're worried about by qualified optometrists who we share care with and respect, but who lack understanding in certain areas and lack training in certain areas. Does that answer your question about malpractice for those specific anecdotes that Doctor. Young mentioned?

[Representative Mary-Katherine Stone]: Not really, because it's my understanding that the federal law puts the burden on the hospitals and the facilities, not the patients.

[Dr. Jessica McNally, President, Vermont Ophthalmological Society]: Think then you get into the

[Representative Mary-Katherine Stone]: Patients are not even aware of this database. Like if I had to pull the room right now, I'd probably be the only person in here besides the people who have to carry malpractice insurance who know about this thing, my patients don't. So I'm just wondering if you had that same understanding.

[Dr. Jessica McNally, President, Vermont Ophthalmological Society]: I think, again, Malpractice is difficult to define, and my experience hearing about malpractice suits brought against physicians and other specialties, including family medicine, including general surgery, including neurosurgery, is that malpractice suits are generally brought by the patients themselves. They're not necessarily brought by another provider, that patients are the ones who come to, for example, the board of medical practice with complaints that are then viewed and looked at to see if it's actually merits a medical malpractice. There's not a definition of what medical malpractice is. Each case is looked at individually.

[Chair Matthew Birong]: I just think something happened.

[Senator John Morley (Orleans District)]: Sure, go

[Dr. Nate Lighthizer, Oklahoma College of Optometry]: right ahead.

[Chair Matthew Birong]: Yeah, please read it

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: up Jeffrey Young, do need me to sit in the chair?

[Chair Matthew Birong]: No, no, no, that's fine from the gallery.

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: Jeffrey Young, ophthalmologist. So a lot of these cases, fortunately in every single one of these cases, no patients received actual harm. It's the theoretical harm that if they would have had the procedure that they would have had. Now, if person who, for example, the first story who had already had the procedure performed and then they would have had it again, And then they would have seen an ophthalmologist who said, What happened here? That may have been something that would have been reportable, but for a patient to be set for something and then the ophthalmologist say, Well, this doesn't need to be done. There's not really much to do for that. There's nothing to report on that other than this referral was inappropriate. If we reported every inappropriate referral, I wouldn't have time to do anything else during the day just based on the number of referrals we get from all kinds of medical providers, just oncologists.

[Chair Matthew Birong]: And we are definitely going to take more testimony on all of this.

[Lauren Hibbert, Deputy Secretary of State]: I just wanted to say that on Hibbert, Deputy Secretary of State, the National Practitioners' Data Bank facilities have an independent requirement outside of malpractice to report. And also, I would say, if there are inappropriate referrals, understanding that all medical providers make referrals when there is the possibility of something, not always when there is a concrete diagnosis. That's frequently why you're getting a referral is because you want a second opinion, you want somebody with more expertise, more knowledge than you to do a review. But if there is repeatedly inappropriate referrals or incompetent practice, I would hope that we would get referrals, complaints to our office for truly substandard care. And we don't receive those complaints. So if that's happening out in the world, and I know this is being watched by a lot of people, if that's happening, please make a complaint to OPR because we do investigate the complaints we receive if there's continual poor care outside of a precautionary referral, which I think all of us should agree is appropriate, we would want to investigate that and provide that any licensed healthcare provider at OPR the ability to obtain more education and training.

[Dr. Jeffrey Young, Comprehensive Ophthalmologist]: Anything else for our guests? I want to

[Chair Matthew Birong]: thank everybody for their patience with the rescheduling from this afternoon into this morning. And then also just a sort of management of moving parts of folks coming in. We're going to hold our last witness over until tomorrow's testimony. We have to be on the floor in twenty nine minutes, and there is a robust calendar for the floor today. So with that, folks, we will be back tomorrow morning, 09:30, and this conversation will be occurring again at some point during the day, so keep

[Senator John Morley (Orleans District)]: it on the agenda.

[Chair Matthew Birong]: With that, Nick, Doctor. McNally, thank you.