Vermont Legislature SmartTranscripts:

[Unidentified meeting host/technician]: Alright. We're live.

[Rep. Matthew Birong (Chair)]: Alright. Good morning, everyone. House government operations and military affairs. It is a little after 09:30, Thursday morning, May the fourteenth. We are picking back up work on S-sixty four, an act relating to amendments to the scope of practice for optometrists. We have some witness testimony lined up for this morning. So we will just jump right into that. I guess we will start off. We'll just go in the order on the list. We'll start with David Hall, associate professor, Southern College of Artificial Biometry joining us. I guess that's one. Yeah, know right.

[Unidentified meeting host/technician]: What is the same? Sorry, my

[Rep. Matthew Birong (Chair)]: eyes are terrible. How are you, sir? Rich Castillo. It's Theo. Yes. Sorry, I'm a plus eight.

[Dr. Rich Castillo]: Yes, here, present.

[Rep. Matthew Birong (Chair)]: And an oblique stigmatism. You know, it's with bad eyes from birth. How are you?

[Dr. Rich Castillo]: I'm doing very well, thank you. So am I first? Is that what I'm understanding?

[Rep. Matthew Birong (Chair)]: Yeah, go for it, man.

[Dr. Rich Castillo]: Take your Okay. All right. Perfect. Well, I appreciate the time this morning. So Mr. Chair and members of the committee, you very much for the opportunity to speak in support of Senate Bill 64. So I am very pleased to join you today and share my professional experience where it would be of value to you. So for the record, my name, Doctor. Rich Castillo. Currently, I serve as the founding dean of the College of Optometric Medicine at the University of North Carolina in Pembroke, beautiful Pembroke, North Carolina. I'm both an optometrist and an ophthalmologist. I first trained as an optometrist and then completed medical school and ophthalmology residency. So I've lived both educational tracks, and I understand the strengths of optometric training, the strengths of an ophthalmologist training, and the difference between procedures that appropriately belong in a modern optometric scope of practice and procedures that should remain outside it. And I will say right now that my opinions, and perspectives are my own. I don't speak, for any other group or entity other than myself, and that comes from nearly thirty years of working daily with optometrists, within an optometric training program, seeing patients in rural America where everyone was expected to utilize the full breadth of their training and talents to provide eye and health care services to communities that were and in many places continue to be challenged in that regard. I practiced for nearly thirty, or excuse me, three decades, thirty years as a comprehensive ophthalmologist and optometric physician in rural Oklahoma. I was, quite frankly, an anomaly. You don't typically find many ophthalmologists practicing in rural America. And if we're to believe the recent ophthalmology workforce study, the workforce adequacy study, which I think you're all familiar with, that is this paper right here. We're not likely to see that change over the next ten years, particularly in non metro and rural communities. I also spent a significant part of my career at the Northeastern State University Oklahoma College of Optometry, where I served as the consulting ophthalmologist, as a professor, an assistant dean, and the chief of the college's surgery service. I was one of the co founders of the NSU Oklahoma Advanced Procedures course, which I understand this committee has heard much about. And through that course and related training programs, I've traveled throughout North America for more than twenty seven years, training thousands of optometrists and optometric office procedures, including the lasers. Okay. I've also had the privilege of training medical residents from the Oklahoma State University College of Osteopathic Medicine. That's my alma mater, as well as providing training in emergency ophthalmic procedures to special forces, soldiers, from Fort Bragg here in North Carolina, during their rotations in my clinic in Tahlequah for several years. My professional background is also in education and competency assessment. As I've just said, I have taught optometry students, residents, faculty, practicing optometrists for over three decades. I've lectured extensively on office based laser procedures, minor surgical procedures, and for decades always had either optometry students or residents following me in the clinic or in the OR. I've also worked with the National Board of Examiners in Optometry, okay, for more than two decades. So I can tell you a little bit about my experience with that organization if interested. I chaired part one, the part one exam, the applied basic science exam during the major restructure of that exam in the early 2000s. I later served as senior director for part three, and that's the live clinical skills examination, which has also been recently restructured. And for more than a decade, I've been involved in the laser and surgical procedures exam, also known as the LESPI exam. Since 2017, I've chaired that examination committee, which is presently composed of three ophthalmologists, one internist, and four optometrists. I can tell you based on my direct firsthand experience that these exams are rigorous, comprehensive, and they assess the intended construct. And that being, is the candidate prepared for the independent practice of contemporary optometry? Now, I see that S-sixty four requires passage of the lesbian exam. That matters, okay, because the lesbian exam is not a simple checklist test. Okay? It assesses critical thinking as applied to lasers and office based surgical procedures. It evaluates whether the candidate understands indications, contraindications, complications, patient selection, clinical judgment, and technical performance. It also assesses technical ability with the equipment and instrumentation used, using high fidelity simulators. And these are the same types of simulators used in ophthalmology training programs. These technical skills can be assessed in a valid and reliable way through an observed structured clinical examination. Now psychometricians call this an OSCE, OSCE exam. And these are developed and administered using psychometric best practices, such as those employed by the MBEO. Now, while everything that occurs in the pre procedure space, meaning history, examination, diagnosis, and co management of surgical patients in the post procedure space, is already the law of the land in all 50 states. I don't believe that that's being debated here, as that is already the scope of optometric practice. Now I believe the central question before this committee, as it always is at these scope hearings, revolves around public safety. So does SB 64, meet that public safety threshold? So my answer is yes. S-sixty four not only meets that threshold, but in my opinion, it exceeds what many states require. And I can tell you that in my three decades of advocacy on behalf of optometry at hearings such as this, This is the most comprehensive set of credentialing guidelines I've seen anywhere. One point I do want to emphasize is that these procedures under consideration do not begin with a thirty two hour course as testimony you have already heard may imply. That's a misunderstanding of optometric education and how optometric education works. Okay? The foundation begins in the first semester of the first year of optometry school. Optometry students spend four years in a doctoral level program focused specifically on the eye, systemic conditions that affect the eye, the visual system, ocular disease pharmacology, emergency eye care, diagnosing and treating visual dysfunctions and medical management of eye disease, including the procedures under discussion here today. And long before a student enters the patient care clinic, that student is learning the natural history of the disease process that lead to these procedures. And they're developing technical skills used daily in routine practice that transfer laterally to all the procedures under consideration here today. So long before a student touches a laser, that student is learning how to diagnose, co manage conditions such as posterior capsulorhepatic pacification. I believe you've heard all this before. Open angle glaucoma, narrow angles, angle closure risk, inflammation, elevated intraocular patient, and other clinical conditions that determine whether a procedure is indicated, contraindicated, or should be referred. And they're also developing and advancing their skills with the type of instrumentation and techniques necessary to safely perform these procedures. And that's crucial because competency is not simply the ability to say fire the laser. Okay? Competency means knowing when to perform a procedure, when not to perform a procedure, how to obtain patient consent, how to manage complications, how to provide postoperative care, and when to refer. Modern optometric education is built around those competencies. NBEO examinations assess and certify that those companies are present or not present. Okay? That's important. I might just add here that the majority of complications, and there's always talk of complications at hearings like this, the majority of complications that we might encounter, say, following a laser procedure, rare as they may be, are not unique to lasers and are already managed by optometrists routinely in all 50 states. And they have been for decades. Rarely does the political opposition mention that fact. This is the modern optometric curriculum then. An optometry program must demonstrate that its curriculum prepares graduates for contemporary optometric practice, and that includes diagnosis, treatment, management, procedural knowledge, patient safety, and the ability to grow with changes in science and technology. Vermont's own Office of Professional Regulations, and I applaud this entity, reviewed the issue and found that standard coursework in US optometry schools provides a strong foundation for the procedures in S-sixty four and that all US optometry schools teach these procedures through didactic instruction, laboratory work, and at a minimum, simulated skill development under structured conditions. Okay. Now with 22 states now offering optometrists an advanced and modern scope of practice, hundreds of externship opportunities exist, for optometry students to receive supervised procedural experience. OPR also recognize that additional hands on training on human subjects is appropriate to complete the training pathway and ensure public safety. And that's what S64 does. As I read it, S64 does not simply say you're an optometrist, therefore you may perform advanced procedures. A licensed optometrist must demonstrate competency and obtain that credential before performing the procedures authorized by the bill. And S-sixty four does not stop with education. It requires high stakes written and clinical skills assessments administered by the National Board of Examiners in Optometry, including the injection skill exam and the laser and surgical procedures exam. And in addition, and this is in addition to the core parts one, two and three, which are the basic licensure examinations. So as someone that's deeply familiar with these examinations, I can tell you that this is a significant patient protection measure. Vermont would not be relying on self attestation or attendance alone at a CE course. It would be requiring independent verification of both knowledge and skill by an independent professional testing agency that's been developing and administering these high stakes exams for over seventy five years and whose sole mission is the assessment of competency and public protection. In addition, S-sixty four also requires in person supervision, and candidates must demonstrate proficiency on live human patients. Okay? The bill requires a minimum number of supervised live patient experiences. The preceptor must be, as I read this, an ophthalmologist or an optometrist with a substantially similar scope of practice and that's been doing this for at least three years, and the preceptor must certify competency and provide a procedure log to the board. The pathway is not simply a thirty two hour course. Okay. Is at a minimum four years of doctoral level education, didactic preparation, simulation, national written and clinical testing, supervised live patient procedures, independently documented and verified competency by an organization whose sole purpose is that with continuing education and even adverse event reporting layered in. That is a serious public protection framework. Now, me be clear about what these procedures are and what they're not. A YAG, you've heard about these procedures, I'm sure, for a while now. YAG posterior capsulotomy, not cataract surgery. Okay. S-sixty four does not authorize optometrists to perform cataract surgery. SLT or selective laser trabeculoplasty, not glaucoma filtration surgery. Okay? It's an office based procedure used as primary therapy in this day and age in the management of open angle glaucoma. Laser peripheral, aerodotomy, the third, laser procedure. It's not broad intraocular surgery. It's an office based laser procedure used to treat or prevent certain glaucoma disemergencies. Now, I'm not trivializing anything here. These are serious procedures. They require training, judgment, respect for complications, but they're also well defined office based procedures that properly trained and credentialed optometrists can perform safely within a carefully regulated scope and have been for thirty years in some states. Thirty years. And of those 22, states, 16 of which are now laser states as well, no state, and I'll emphasize this, no state has ever had to reverse its stance and take those privileges away. Okay? I think that should speak volumes. S-sixty four draws a line in a clinically, reasonable place. Okay? It expressly prohibits optometrists from performing retinal laser procedures, LASIK, corneal transplants, general anesthesia, cataract extraction, surgery of vitreous or retina, intraocular injections that penetrate the globe, and many other procedures that are appropriately outside the bill. K? The bill is not asking Vermont to turn optometrists into ophthalmologists. K? It's asking whether specially trained and vetted optometrists should be allowed to perform a limited list of office based procedures after meeting a credentialing threshold that includes education, national examination, supervised procedure, know, maintenance of procedure logs, continuing education, and adverse reporting, adverse event reporting. OPR, reported that 25, this is my reading. OPR reported that 25, states already allow optometrists to practice at a higher level than Vermont in that 14, Well, now 16, actually, states allow a scope substantially similar to s 64 with many less stringent requirements. Okay. So OPR further stated that s 60 four's training, testing, and reporting requirements would make Vermont law among the more stringent one of the more stringent jurisdictions that permit this higher scope of practice. And in fact, as far as I know, this would be the most comprehensive credentialing pathway in the profession. Okay? And that's exactly the balance Vermont should want. Okay? Modernized access, but with strong guardrails. The bill is also about modernizing antiquated scope of practice acts that prevent optometrists from continuing to grow with the science and technology. Again, in some cases, outdated laws can force optometrists to practice below acknowledged or emerging standards of care. Patients don't benefit. Okay? Patients do not benefit when a statute falls behind the science. Patients do not benefit when trained professionals are prevented from providing care that is within their education, demonstrated competency, and state oversight. Okay? So to me, the proper question is not whether optometrists and ophthalmologists have identical training. They don't. Okay? In in in many respects, they don't. The proper question to me, is whether the specific training pathway, detailed in s 64 is sufficient for the specific procedures authorized in s 64. K? And my answer to that is yes. Okay. So S64 is not a blank check. It's not automatic scope expansion for every optometrist. It's a carefully regulated specialty pathway for qualified optometrists who complete the required education, national board examination, supervise my patient training, submit their logs, continue education, and adhere to prescribed adverse reporting. K? So it it improves access while preserving public protections. It modernizes, your law, k, Vermont law, while keeping clear limits. It allows optometrists who meet the threshold to practice up to their demonstrated competency but without authorizing major ophthalmic surgery. So, for those reasons, I respectfully urge you to vote yes on s 64. Again, thank you. I've taken up way too much of your valuable time, but I thank you for the opportunity to speak, and I'd be happy to respond to any questions you might have.

[Rep. Matthew Birong (Chair)]: Yeah. No, thank you very much. That was very useful information. It did not take up too much of our time. It was very well utilized. So I have two hands. I have Rep Nugent and Rep Stone.

[Rep. Kate Nugent]: You said that you don't think patients benefit when professionals aren't able to practice to their full capacity. So I was wondering if you could talk more about your thoughts on that.

[Dr. Rich Castillo]: Sure. Well, let me just give you an example right up front. We know, thanks to some studies that have been conducted recently, going back about five, eight years, that, for example, open angle glaucoma, okay, which is one of the big drivers of visual disability and economic burden, okay, within the system. In fact, here in North Carolina, where I am, the state of North Carolina, a very rural state such as Vermont, has an economic burden of visual disability of somewhere in the neighborhood of $4,100,000,000. Billion dollars. Conditions such as glaucoma, specifically open angle glaucoma, are one of the drivers of that, along with diabetes, some others that we all experience in our communities. But, you know, primary therapy for glaucoma has evolved. The knowledge base has evolved. The science has evolved. The technology has evolved. In this day and age, we know that if we perform SLT, the selective laser trabeculoplasty, on a patient before we start them on traditional eye drops, they will do better, and they will do better for longer than if we go the more expensive route actually of prescribing eye drops first. Laser takes away the whole problem with compliance with eye drops, with the cost of eye drops. It is primary therapy. Okay? And in many, many states where optometrists do not have the privilege of utilizing that procedure, which by the way, they are you know, they technically an optometrist begins to learn, the methodology for doing that procedure. Okay. That procedure utilizes a laser. The laser interface is through what we call a slit lamp or a biomicroscope. That's the instrument that you put your chin in when you go to the eye doctor. It's a microscope that they use to examine around and inside the eye. That instrumentation, that technique, that skill begins the first, sometimes the first semester of optometry school. So, you know, by the time an optometrist finishes their training program, they have mastered that technique. Now, what they do, what you need to understand is they will take those skills, which they utilize routinely every time they see a patient, and transfer that skill laterally to this other procedure we call an SLT. Essentially, you're doing a slit lamp examination and focusing on the area of regard and then pushing a button which fires the laser. That laser, by the way, is a nonthermal laser. It does not burn. Okay? It's not like you know, I talk to patients about lasers and their concept is the death star from Star Wars blowing up in their head. No. Okay? This laser does not do that. But in states where the scope of practice is antiquated, an optometrist is not able then to practice up to the standard of care because of restrictions, you know, within their scope of practice. That does not serve the public welfare, in my opinion. So that's hopefully, answers your question, but that's just one example where antiquated scope of practice laws really hold back the practitioner from delivering services consistent with standard of care.

[Rep. Mary-Katherine Stone]: How many of the 24 optometry schools in The United States are located in states where the laser procedures are currently legal for optometry?

[Dr. Rich Castillo]: I think in twenty seven years of attending conferences and meetings like this, that's always asked. So right now, Oklahoma, Indiana, and Kentucky. Well, I have to actually add Memphis, Tennessee. So Tennessee. Tennessee just modernized its scope of practice a few weeks ago. So it's those four.

[Rep. Mary-Katherine Stone]: Okay. So four

[Dr. Rich Castillo]: No. I was just going to say that doesn't mean necessarily that students in other states don't get the practical experience. I think that's, you know, what the is the other question that's always asked. Well, sure, you can teach, you know, in the class classroom and you can simulate in lab, but where do you get practical experience? You know, we're up to 16 states now with and we're just talking about lasers. Okay? Not all the other procedures, but 16 states now. So there are thousands and thousands of ODs in practice now within jurisdictions where they can perform these procedures and service externship sites for students from other states wanting to come and get some practical experience, you know, in these procedures. So my prior institution, NSU, for example, had a and they I believe they still do had an arrangement with the University of Houston College of Optometry. Now you cannot perform these procedures in Texas because Texas's law is still restrictive in that way. But every semester, at least while I was there, I think half a dozen students, rotated through every semester, fall, spring, summer, through Oklahoma. They came. They lived, in Tahlequah. They were assigned to our clinics. They rotated through all these services, laser and surgery included, with the specific intent of providing experiential opportunities to students from states where the scope of practice restricted their programs from allowing that type of training within their state.

[Rep. Mary-Katherine Stone]: Could I just add a follow-up? So there are 24 optometry schools that I'm looking at in The US. So could you say, you said there are four states now?

[Dr. Rich Castillo]: There are four states, Oklahoma, Kentucky, Indiana, and Tennessee, located, yeah. So four schools located in states where the scope of practice has advanced to this level.

[Rep. Mary-Katherine Stone]: Okay. So that's four out of I'm guessing the the remaining 20 schools would not be located in states where this has been expanded then?

[Dr. Rich Castillo]: Right.

[Rep. Mary-Katherine Stone]: Okay. So still the vast majority of students coming out of optometry programs do not have that hands on training that typically their curriculum unless I know they go to another state to get it, but just in the general curriculum.

[Dr. Rich Castillo]: Or or I know that there are several programs that actually bring ophthalmologists in. And so, you know, under the auspices of an ophthalmologist that's licensed to provide those services in that state, you know, they can utilize students and residents in, you know, whatever capacity they they see fit, you know, as long as it's it's ethical and proper and safe. So, you know, I do know that there are students that do actually get some hands on, you know, working under the auspices of a licensed physician.

[Rep. Mary-Katherine Stone]: And then, sorry, one more follow-up question and I'll stop. But of the thirty two hour certification course that you referenced earlier, how many of those hours are actual hands on live patient procedural training versus the didactic or classroom instruction?

[Dr. Rich Castillo]: Yeah. The Oklahoma course, there's no live patient. There's actually no live patient. Those procedures are not being performed. And in many instances, those courses are, again, are taking place in states such as Vermont that are trying to advance scope of practice, but yet, you know, those procedures are still not legal for optometrists to perform in that jurisdiction. Know? And that's always been a catch 22 because, again, these antiquated scope of practice laws really handcuff training programs and prevent them from, you know, doing what ophthalmology is saying. Well, you should be seeing more live patients. Well, we would love to if we could get around that little catch-twenty two where we can't because we're in a jurisdiction that doesn't allow that. You know, my medical license is I was an intern and a resident, when I was a resident, as soon as I graduated, I received a diploma that said physician and surgeon. Well, I can tell you I was no surgeon, okay, when I walked across that stage. I had never performed a surgery by myself, okay, after four years of medical school. And yet I have this piece of paper that says physician and surgeon. And then at the end of my internship year, so first postgraduate year, where I spent rotating through every department in the hospital, you know, except for ophthalmology, then I get a medical license. So all of a sudden, I have a medical license before I actually train to what I intend to be doing for the rest of my life. But medical education is structured such that that's not a problem because you do have these training licenses, these plenary licenses, which allow the training to take place. Optometry finds itself in a difficult position in places where the scope of practice as defined by statute says no. And that's been a challenge, and it continues to be a challenge. Okay? So optometry, you know, is working around that as best they can. Again, we have to keep up with the science. We have to keep up with the technology. You know, we have to evolve just like every other profession. And, you know, regardless of, you know, the the problems, you know, built into the system, you know, we have continued to advance. When, you know, when I started this, when I finished my ophthalmology residency and went right back to to NSU Talequale, there were zero states that had lasers or surgery. And within the span of my career anyway, you know, '22 now, we're almost at the halfway point. K? We'd be a little bit further along, you know, were it not for the fact that the legislative process takes time and it's expensive, and we have these, you know, political groups opposing, you know, almost everything that optometry is trying to do in that regard. And yet we're almost at the halfway point.

[Rep. Matthew Birong (Chair)]: Doctor. Evans.

[Rep. Chea Waters Evans (Ranking Member)]: Thank you. So I would say, I will ask you this question, I'm happy when it's time for his testimony for our next guest to answer it as well. So I heard you use the words political opposition when you were speaking. And this seems to me like it's about safety for patients and expanding access. So can you tell me what you mean when you say this political and what the opposition is?

[Dr. Rich Castillo]: Well, so again, I've been doing this for about twenty seven years. What I've heard this go around in Vermont is exactly what I heard twenty seven years ago. Know, when you get to the national level, everybody retreats to their respective organizations. And, you know, I can't blame anyone for that. You know, we we see not to, you know, make a visual pun here, but, you know, we see things through the lenses, you know, based on our our training experience. You know? If I'm if I'm an ophthalmologist and I've never stepped foot in optometry school or I don't work directly with optometrists, you know, I have a very limited understanding of what modern optometric training is. You know? Maybe the only optometrist I know graduated forty years ago. I you know? So, the the political arguments, you know, are always made to serve this, you know, respective political agenda, and that's just the way it is. But I will tell you, you know, once, in these states that have, you know, advanced their scope of practice, once that happens, you know, on a day to day level, everyone gets gets along very well. You know, ophthalmologists, you know, continue to work with optometrists and vice versa. You know, I will tell you that some of the largest ophthalmology, optometry practices that I'm aware of utilize everyone to the full extent of their capabilities for, you know, the benefit of their patients. You know, I know ophthalmologists that that don't do any of these procedures. You know? They rely on their optometrists, you know, within their group to perform these procedures, you know, freeing up ophthalmology to do what it uniquely is positioned to do.

[Rep. Chea Waters Evans (Ranking Member)]: Yeah, I guess my concern is the political aspect. When you say people go to their respective sides and there's like this whatever's happening, I just I feel uncomfortable and not because of what you said. You're you're fine. You personally. But when I discuss this with other people, here's what I hear. It's political. It should not be political, in my opinion. No, it's about it's about people's eyeballs. And that's where we need to focus. Right.

[Dr. Rich Castillo]: And then

[Rep. Chea Waters Evans (Ranking Member)]: I also heard people say, and I would love for you to speak to this as well, that people have said to me, you know, not on the record, just kind of these offhand conversations in the hallway, Oh, this is about money. This is about optometrists wanting to make more money. This is about ophthalmologists wanting to protect the money that they're making from this. And I just don't think we've quite addressed that in our committee discussions yet. And it's something that I think is important that if you can speak to that, I would really like to, because I would like to think that this is about patient safety. It's about training.

[Dr. Rich Castillo]: It's

[Rep. Chea Waters Evans (Ranking Member)]: about improving access. It's about making sure that we are handling things the right way. And it makes me feel distinctly uncomfortable to hear people say things like political opposition and they want to make more money. That is really bothersome me. I just need some context for that and some understanding.

[Dr. Rich Castillo]: Sure. And I appreciate where you're coming from there. I don't think it's either extreme. I can tell you, again, as a physician, is a calling, to be an optometric physician, to be an ophthalmologist. I don't think anyone gets into this business just because they want to make money, because you're giving up so much. You're going to become a physician. You're going to become an optometrist. You're going to be on call constantly twenty four hours a day. You're going to have to sacrifice family time. You're not going to have a regular sleep pattern after residency. Any normal sleep cycles that you had are gone. Have to be available twenty four hours a day. Mean, this is a calling short of the priesthood or something. You really have to be, you know, of a mindset that this is what your life is intended to be. So it can't be about the money because there are much better ways of making money than doing this. I will tell you that from some

[Rep. Chea Waters Evans (Ranking Member)]: Yeah. The context of saying they wanna expand their their practice because they're it it enables them to make more money, not because anyone's as a state legislator, I will tell you none of us in this room are in it for the money. So I hear you very much.

[Dr. Rich Castillo]: And honestly, if you look at what the reimbursement for all of these procedures, it's not that much more than what we might say routine eye exams. In fact, let's compare apples to apples here. You do one of these procedures. The laser procedure is probably going to reimburse the best, depending on where you are, dollars 300 or somewhere between $250 and $300 per procedure. I do a general eye exam on someone, you know, and maybe $150 And if there's pathology, if I do any ancillary testing, photos, retinal scans, whatever, maybe tack on another $40.50 dollars there. And then I give them a prescription. They go to my dispensary and they pick up a pair of glasses, which in this case, dollars 700,000. I'm actually making much more money just doing general routine eye care than in any of these procedures. So again, I don't think people are doing this for the money. I will tell you that and we hear the argument about access to care. Well, know, this really isn't expanding access to care or there's an ophthalmologist twenty minutes down the road. You know, no one is deprived of ophthalmology care. Well, yeah, they may be ten, twenty minutes down the road, but that's assuming the patient is mobile and they can get there and they have a car or in this day and age, they can afford the gas. Or that that practice, which is twenty minutes down the road, actually has an ophthalmologist that's there full time. Okay? I'm in a town right now. UNCP is in a town of about just a little under 3,000. Now you go twenty minutes this way and you're in a town of about 20,000. And, yeah, there's an ophthalmologist there. They're not there full time. That's a satellite clinic. And I will tell you, you wake up in a small community like Pembroke, North Carolina with a painful red eye at three a. M. And you're going to know what access to care means. I mean, you're going to know what lack of access to care means at that moment in time. Okay? And you're going to hope that there's an optometrist that can do maybe a thirty second procedure, which is going to resolve your emergency and preserve your vision rather than have to worry about where am I going to go in the middle of the night to find someone that can do this office procedure for me.

[Rep. Chea Waters Evans (Ranking Member)]: Thank you.

[Dr. David Hall]: You're welcome. So

[Rep. Matthew Birong (Chair)]: I think we're gonna skip over to her or move over. Thanks so much for the time, sir. That was very valuable testimony and information.

[Dr. Rich Castillo]: Thank you.

[Rep. Matthew Birong (Chair)]: I see we've been joined by Doctor. David Hall. How are you, sir? Professor of Southern College of Optometry.

[Dr. David Hall]: Very good, thank you. Thanks for the invitation to be here this morning.

[Rep. Matthew Birong (Chair)]: Absolutely. Table is yours. Please go. Feel free.

[Dr. David Hall]: Okay. And stop me at any point if I start getting too lengthy.

[Rep. Matthew Birong (Chair)]: No worries.

[Dr. David Hall]: My name is doctor David Hall, and it is a privilege to be addressing this committee this morning. I've been an optometric physician for over thirty two years. And for twenty two of those years, I practiced in Oklahoma for safety, where I safely and successfully performed the laser procedures addressed in this legislation. I currently serve as an associate professor at the Southern College of Optometry in Memphis, where I teach these same procedures to future optometric physicians. I appreciate the opportunity to speak today in support of modernizing Vermont's optometry laws through S-sixty four. So they accurately reflect the education, clinical training and competency of today's doctors of optometry while improving access to care for the citizens of Vermont. Across the country, optometry has evolved alongside advances in education, technology and patient care. Today's optometric physicians are trained to diagnose, manage and treat a wide range of ocular disease, including advanced medical and laser procedures that have become standard components of optometric education nationwide. Yet in many states, including Vermont, statutory language has not fully kept pace with that evolution. All 24 accredited schools and colleges of optometry in The United States, Canada, and Puerto Rico teach the procedures addressed in this legislation. In many institutions, these procedures have become part of the curriculum for more than three decades. These are not experimental techniques or fringe concepts. They are well established, standardized components of modern optometric education. They are required components to adhere to accreditation requirements of the ACOE Accreditation Council in Optometric Education. At the Southern College of Optometry, where I have the privilege of teaching, students receive extensive didactic and clinical preparation in laser and advanced procedures. Third year students train in our anterior segment ophthalmic lasers laboratory where they learn multiple ophthalmic laser procedures in very small group settings under direct faculty supervision. Before progressing, students must demonstrate competency through practical examinations modeled after national board testing addressed actually in this legislation. During four year externships, students participate in laser and medical eye clinics where they gain hands on experience in patient education, perioperative care, complication management, and procedural decision making under the supervision. Sorry. Lost my notes here.

[Rep. Matthew Birong (Chair)]: No worries. No worries. It's all good. Take you get yourself organized.

[Dr. David Hall]: Yeah. Under the supervision of experienced physicians, they graduate with a deep understanding not only of how procedures are performed, but more importantly, when they should be performed, when they should not be performed, and how to recognize and manage complications appropriately. That foundational medical education is very critical. Optometric physicians have also been safely performing many of these procedures in other states for more than thirty years. Currently 16 states with Tennessee being the last allow optometric physicians to perform the procedures outlined in this legislation. During that time, the safety record has been exceptionally strong and not one state has removed any of these laws after successful passage. The large study that Doctor. Casteel was just talking about of over 145,000 patients treated by optometric physicians demonstrated an adverse complication rate of less than zero point zero zero one percent, completely in line with our ophthalmology colleagues. That is an extraordinary high level of safety and speaks directly to the quality of education, clinical judgment, and procedural training within the profession. It's also important to recognize that optometric physicians already have decades of experience diagnosing, monitoring, and treating the very complications that can potentially arise from these procedures. Managing intraocular pressure spikes, inflammation, corneal complications, ocular infections, medication reactions, and post procedural follow-up care has long been a routine part of optometric medical practice. These are not unfamiliar situations to our profession. They're conditions that we evaluate and manage every single day. In every healthcare profession, new technologies and procedures continue to emerge after graduation. Ophthalmologists who graduated before the 1990s were never trained in residency on procedures such as LASIK, anti VEGF injections, or minimally invasive glaucoma surgery. Yet as technology evolved, they pursued continuing education, reviewed clinical literature, trained with experienced colleagues, attended courses, and incorporated those procedures into practice safely and responsibly. Medicine has always functioned this way and optometry is no different. The question before this committee is not whether optometrists are capable of safely learning and performing advanced procedures. They already possess the foundational education in ocular anatomy, pharmacology, laser physics, disease management, and complication recognition necessary to do so. The question is whether Vermont law should allow appropriately trained optometric physicians to utilize those skills for the benefit of Vermont patients. Importantly, S-sixty four contains extensive safeguards and oversight measures that ensure these procedures are introduced safely and responsibly. This legislation was carefully reviewed and vetted, including through the comprehensive analysis conducted by the Vermont Office of Professional Regulation. The bill establishes clear educational and competency requirements for any optometrist seeking procedural privileges. Under this legislation, optometrists would be required to complete additional approved educational coursework, including a thirty two hour advanced procedures course for those graduating after 20 They must successfully pass both the laser and surgical procedures examination and the injection skill examination with the board of examiners in optometry. They must also perform and complete formal preceptorship with either an ophthalmologist or an experienced optometrist authorized to perform these procedures. In addition, they must complete multiple proctored procedures demonstrating competency across the specific procedures authorized under the bill before independently performing them in practice. It also clearly defines what remains prohibited. For example, optometrists would not be perform be able to perform intravitreal injections or other high risk surgical interventions outside the scope outlined in this bill. The legislation further requires advanced event reporting and additional continuing education requirements focused specifically on advanced procedures and patient safety. These are substantial safeguards. And importantly, they mirror the type of postgraduate procedural training pathways commonly used throughout healthcare professions when new technologies and procedures are adopted into clinical practice. At its core, this legislation is about safe patient access. Vermont, like much of the country, faces increasing challenges in access to routine health and specialty eye care. Rural communities are particularly affected. National workforce projections continue to show growing demand for eye care services alongside projected shortages in ophthalmology over the coming decade. At the same time, our population is aging with rates of diabetes continuing to rise and diseases such as glaucoma and macular degeneration becoming increasingly common. Patients often wait weeks or months for specialty appointments that could potentially be managed more efficiently and effectively locally by appropriately trained and trusted family optometric physicians. Modernizing scope also helps address that gap. It also matters greatly for recruitment and retention of future providers. As an educator, I can tell you that today's students want to practice where they are allowed to fully utilize the education, the training that they've worked so hard to obtain. They're comparing opportunities across states when deciding where to establish practices, raise their families, and build their careers. And states that modernize their laws are more attractive to new graduates. States that do not risk losing highly trained providers to neighboring states with broader practice authority. That reality affects access to care, particularly in rural and underserved communities where recruiting health care providers is already a very difficult task. Passing S-sixty four would send a strong message that Vermont is committed to maintaining a modern healthcare workforce and expanding patient access while preserving strong safeguards and oversight. The educational infrastructure already exists. National board examinations already test these competencies. Accreditation standards already require this training. The safeguards outlined in this bill are are robust and thoughtful. And perhaps most importantly, the real world experience from other states over the last three decades demonstrates that optometric physicians can perform these procedures safely, effectively, and responsibly. This legislation is not about expanding health care recklessly. It's about aligning Vermont law with modern education, contemporary standards of care, patient needs, and responsible oversight. Most importantly, it's about improving timely access to high quality care for the people of Vermont. Thank you so much for your time, your thoughtful consideration, and your commitment to the health and vision of Vermont citizens. I will be happy to take any questions you might have.

[Rep. Matthew Birong (Chair)]: Restown.

[Rep. Mary-Katherine Stone]: Yes. Going back to the beginning of your testimony, when you said that all schools teach these procedures, do you mean they teach the theory or do students actually perform them on live human patients? And if the latter, how would a school in like Massachusetts or New York, for example, where it's illegal arrange that?

[Dr. David Hall]: That's a great question, representative. Thank you. I can't speak for every school and exactly I I have a lot of contacts throughout the country with other optometry schools. I know that everyone teaches these to the level that accreditation requires, which is didactic and hands on. Now that hands on may appear different in different schools because different schools may not have implemented quite the way that the schools in laser states have such as Indiana, Oklahoma, and Kentucky. I know in Tennessee, we were able to, before we became a laser state and even now while our board rules are still being approved by the Senate and the House, We do live procedures on patients here in our clinic system because I have an ophthalmologist that we have contracted with that, by the way, felt like we should have been doing these procedures twenty years ago. And he comes in on Tuesday afternoons and he and I proctor the students on live patients. Now I can't say that other schools do that. That would be the way that we worked around that because we know because we have students from, right now in our first year class, have students from 32 different states. And so with my students going all over the country to practice, we wanted our students to have hands on experience whenever they went to other states. Now other other schools, I don't know if they do that. I know that Oklahoma does live laser cases. The school in Pikeville, Kentucky, as well as Indiana and here in Memphis is Southern College.

[Rep. Mary-Katherine Stone]: Okay, thanks. And just one follow-up question. If the board exam test these competencies, why is it an elective rather than required for licensure?

[Dr. David Hall]: Are you talking about the national board exam or the lesbian test that's required in Yeah, S-sixty that's a great question also. Really good question. So not all states, because we are a state legislated profession, every state has slightly different rules promulgated, especially, well, whenever it comes to most anything in optometry practice. There are some states that require the lesbian exam. Other states may not require the lesbian exam at the national level, but they may require they all require you to take a state board written exam and also practical exam. I've been a part of that practical exam now a couple times in Mississippi as well as every year in Arkansas since the passage of their laser bill six years ago. And so each state, I don't know yet what Tennessee's promulgated rules are going to be. There's some talk that we may require everyone in in Tennessee to take the lesbian exam. That that is a bit of an ask because it is a fairly expensive exam and the practitioner has to get to Charlotte, North Carolina for at least a two day trip. And so that's a fairly big ask for practitioners that have busy practices to get away and spend that kind of money. But I would not be opposed to I think it's fantastic that you put that into this law that any time that we can do something at a national level, I think that's good, but not every state has adopted that practice.

[Rep. Matthew Birong (Chair)]: New gen.

[Rep. Kate Nugent]: Thank you. I know we're we're talking a lot about rural areas and access and drive times and that kind of thing. And I was wondering if you could talk a little bit about how you would anticipate what happens if someone in that area has complication that an optometrist is unable to manage? And I'm also thinking about second opinions in a space like that and how important or if optometrists are also usually on call.

[Dr. David Hall]: Yeah, another really excellent question. You've done your hard work getting ready for this. I appreciate that. Very similar question came up in Tennessee this spring. We, as optometric physicians, we all have referral practices in place because we have been treating complications. We've been looking for complications for decades now. All of us have really close relationships with ophthalmology, with specialty practitioners, that whenever we see a complication that we either want a second opinion on or we want to send out for consultation, those are already in place for all of us. And so if I have a patient for instance that I've never had this happen, but in case I were to do a laser procedure on a patient and they were to have a subsequent retinal detachment, again, I've never had that happen. Doctor. Chisteille may have had in his professional life, but I haven't yet, knock on wood. But if that were to happen, that would that would that referral would be made the exact same way that it would be made in my office, whether it had anything to do with with performing a laser or not. I would get them immediately to the the retinal specialist, just like I would for any other retinal problem that were to come into my office that's out of my scope of practice. And yes, whenever we perform, I think every state that I've ever worked with in these procedures, every state I'm licensed in, I'm licensed now in three states that allow these procedures. And each of those three states require me to have twenty four hour access to my patients or patients have twenty four hour access to me. So anytime you're going to be performing these procedures, one of the last things that I do as the patient leaves the office is they're given my emergency telephone number and they know exactly how to get in touch with me. And so I'm on call whenever I do these procedures. I'm on call right now. Whenever my students do these procedures, I am the on call doctor for any problems that might arise or any questions that a patient has.

[Rep. Kate Nugent]: Just one moment. I was wondering if you had a chance to look at our witness testimony on our page and the chart from Jessica McNally about comparing the education tracks and if you agree with that and what your thoughts are. And if

[Dr. David Hall]: you I'm sorry. I have not had a chance to look at that, but any specific questions you have about what my feelings might be about it, I'd be happy to answer that. That's one that's one document I was not able to preview.

[Rep. Kate Nugent]: If you do have a chance to look at it, I would love your thoughts. I don't have a specific one, but it's that would be helpful at some point. Okay.

[Dr. David Hall]: I'll have somebody send that to me, and I'll be happy to take a look at that, by all means.

[Rep. Matthew Birong (Chair)]: Any other questions, Cardinal? Seeing none. Okay, thank you very much for your time, sir. Thank you. If it's anything you feel compelled to follow-up with, please feel free. Alright, committee, we were scheduled to take a break for a couple of minutes in between these sorts of testimony, but we do have representative Yakamani here who is scheduled to testify. So I want to be conscious of his time. I'm gonna give him the chair for the duration of his testimony, and then we'll call a time out for a couple of minutes for us to stretch our legs, etcetera.

[Rep. Dave Yacovone (Guest witness)]: Yeah, thank you, Mr. Chair. I think I'll be very, very brief. Thank you. I'm sure it's succinct

[Rep. Kate Nugent]: as well. Oh, that's it.

[Rep. Dave Yacovone (Guest witness)]: Yeah. I'm very grateful for the opportunity and the time you're able to a lot me on this. I've done a little research and I think what I am looking for is accommodated in the bill. I have something called macular degeneration. I've been receiving injection in my eyes for over ten years. Used to be both eyes, but I've lost one eye and the other eye were working hard to preserve. So every six to eight weeks, I get an injection. And my ophthalmologist was counseling me, and he knew the bill was coming and he said, Dave, macular degeneration is different. And I listened to him, over my years of experience, I've had several incidents when things went astray. These things happen, I guess. So I'm on guard and I listen and I wanna be careful. He may be biased. I guess we all had certain issues, but I wanted to listen to him. But I found in the bill the help of someone who pointed it out to me. It's a page seven line one, and I realized page numbers when bills change, section seventeen oh two, where it appears that macular degeneration is exempt in this bill. And I I would ask that I I would hope you would keep it that way. You may have already changed it for all for all I know, but I I'd be grateful that folks would keep that language there as it was presented to you in in the bill.

[Rep. Matthew Birong (Chair)]: Yeah. The bill currently

[Rep. Dave Yacovone (Guest witness)]: stands unamended as it's come down. So, we haven't touched anything yet at SARS Coffin. I'm I'm not a specialist on eyes. I'm just some lived experience and I couldn't do much more scientifically to ask, but I I'm cautious with with these things.

[Rep. Matthew Birong (Chair)]: Absolutely understandable, sir. Thank you so much.

[Rep. Dave Yacovone (Guest witness)]: That keeps it under a minute.

[Rep. Matthew Birong (Chair)]: Oh, that was quite efficient. Remember. The Q and A is now starting, you're not free. Ready to go.

[Unidentified committee member]: No question. I just wanted to comment, Representative Iacavoni, that I have long said that this really isn't the committee to change medical procedures because we're not the healthcare committee. So rest assured that we'll stay that way in Bill. Thank you being here to say that.

[Rep. Dave Yacovone (Guest witness)]: Thanks for listening. Any other questions or anything on the Stowe Charter you want

[Rep. Matthew Birong (Chair)]: to help? Oh, guess I'm glad you're speaking on this morning. I

[Rep. Dave Yacovone (Guest witness)]: couldn't help myself.

[Rep. Matthew Birong (Chair)]: Opportunity, sir, Steve. I would expect nothing less out of you. Have a great day. Yes. No, thank you. Thank you. All right, committee. We are a little bit behind schedule, but we baked plenty of time in the morning for this. I do want to call a ten minute break just for us to have a ten minute break before we get in slugged. So we will be back here. We'll call it well, did it. We will come back at 10:50. Nick,