Vermont Legislature SmartTranscripts:

[Representative Matthew Birong (Chair)]: All right, everyone, thank you. Welcome back. Continuing work, witness testimony on S-sixty four Act relating to amendments due to the scope of practice for optometrists. And before I get on to the other witnesses, it seems Doctor. Hall has had time to review the sheets that representative Nugent referred to and has some response. So Doctor. Hall, table is yours.

[Dr. Hall]: Yeah, thank you again. Let me go through just a couple of comments that I would have regarding the differences here. The just working my way down through this, the optometry school, four years, the limited pharmacology training, disease training. Actually, it's very it's very heavy disease based now, very heavy pharmacology based and procedure training in optometry school, in within the ten thousand hours, of the programs. Many of the clinical residencies that are available now throughout the country are also disease and surgical based. And so that includes lasers and chalazzing these minor surgical procedures that this bill addresses. There is an equivalent pathway for fellowship now. There are fellowships available, different training, fellowship training options available in The United States for optometric physicians. The the as far as what is done in a in an ophthalmology residency, the actual required laser procedures and this comes straight from the accreditation, council for medical education are quite low. The, number of procedures that are are required, for somebody to get through a residency are quite low. I think it's five YAG procedures for the other two of the SLT and the LPIs. And then the standard scope for ophthalmologists actually does not include retinal detachment repair and corneal transplants. That would be a fellowship trained thing and so that difference appears to be quite a bit wider. But those are just the the comments that I would have based on what I'm seeing there.

[Representative Matthew Birong (Chair)]: Thank you for spending the time on that and the response, sir. It's appreciated. Thank you. Okay, moving on to our next witness, Matthew Birong. How are you doing, sir?

[Dr. Danielle Phillips, OD]: Well, how are you?

[Representative Matthew Birong (Chair)]: Good, thank you. Good.

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: Mr. Chair and committee, thank you for seeing me this morning. My name is Matt Greenberg. I'm an emergency physician by training. I've got about twenty five years of experience as an emergency physician. I've been here in Central Vermont for the last sixteen years. I am here mainly to speak as I'm currently the chair of the Vermont Board of Medical Practice. We were asked to review this bill, come up with a consensus opinion, and I was asked to share that here with you all today. I need to start off by saying I am not an eye doctor, I am not an ophthalmologist, I do not do any of these procedures personally. I do take care of some eye emergencies, but in general, we leave the eyes to the ophthalmologist when we have serious problems. So I can't address the very specific details of any of the procedures. I thought before I went too far that it would be important to explain what and who the Vermont Board of Medical Practice is, just in case you don't know, I don't want to assume. We are a group under the Department of Health. We are all appointed by the governor or a governor. It is currently 16 of us, nine are physicians. I'm sorry, eight are physicians, one is podiatrist, one is a physician assistant, and the remainder are community members with no medical training. We license 6,000 individuals in this state to practice medicine. Those are MDs, physician assistants, radiology assistants, anesthesia assistants, and podiatrists. There are obviously other practitioners that practice medicine that are involved mostly through APR and the other boards. We were asked to review this bill, and we've actually reviewed this bill and several bills over the last three years. Each and every time this bill has come to us, we have recommended opposing it. We don't take that lightly. We know this is a hot topic. We know that there's a lot of pressure for it. We need to look at our responsibility, our goal, our only responsibility as a board is for the safety of Vermonters and their medical care. That usually comes into one of two flavors. One, we license all of those individuals I talked about. And two, we review any and all complaints, litigation, anything, any allegations that's been alleged against one of our licensees to ensure that there isn't somebody in this state practicing that shouldn't be practicing. So our whole mandate is safety, and that's the lens with which we made this opinion. So in looking at the bill and the reasons to vote for the bill, it sort of came down into two or three major areas that people have been talking about, one of which is access, one of which is cost. I'll address those two things. And then for us, it always comes down to quality and safety. So sort of three separate areas that we were looking at when we made this opinion. In regards to access, the bill, the goal, we want our Vermont citizens to be able to get access better. And unfortunately, the data here just does not support that access is going

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: to improve. I don't know

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: if any of you have tried getting into an optometrist lately. There's a very long wait. Giving optometry more procedures is not going to reduce the current weight. So it is not going to make things better. But that's all anecdotal. As physicians, we like looking at research. And is there any research out there? Well, OPR in their 2023 analysis also couldn't find that there'd be any benefit to access. There is one journal article that we found when we were looking, a 2023 study in the Journal of Ophthalmology. They looked at several states that had similar legislation earlier on, and they looked at travel time, which they used as a surrogate to access, and they found that there was no difference before and after the bill was passed. And so once the practitioners had this skill available to them, they did not find that there was any benefit to access. So we have concerns that the major pushing point of this bill really isn't going to play out. So we took that off as, well, if there's no benefit to access, let's not discuss access. So the next part we talked about was cost. I think as Vermonters, we're all very aware of the cost of medicine right now. I don't go through a single day questioning whether or not I should be doing a procedure for cost reasons. I mean, cost is huge, Green Mountain Care Board, etcetera. Unfortunately, again, looking at the information that's available, and there's not a lot, I freely admit, there's not a lot of information out there, there's been no data to prove that there would be a cost benefit. Again, OPR's own 2023 analysis said they could not determine if there would be a cost benefit. There are certainly concerns that when you open up a new skill to a group of practitioners, that skill tends to get used more potentially in patients that don't necessarily need it or need it at that time, that actually increases cost. There's also the potential for side effects, etcetera, complications. That all plays into cost, but again, it's really hard to quantify that. So we said, Well, there's nothing really that we can find anywhere that's going to show that this is going to improve costs. So we took cost and access off the table, and that left us with our mandate safety. And when it came down to it, we did not feel that the safety implications of allowing this group of very skilled people, but not necessarily as skilled as the ophthalmologists that are doing this procedure now. And a lot of that comes down to when we look at quality and safety metrics in medicine, most of it comes down to numbers. There's a lot of data out there from all kinds of different organizations, the IHI, the AMA. What they look at is how skilled a practitioner is directly reflected in how many procedures they do. That's why we have minimums. If you're a surgeon, you have to do so many gallbladder surgeries to be able to maintain your proficiency. In initial training, the length of training for an ophthalmologist, ophthalmologist, so four years of med school, followed by four to six years of residency plus fellowship, during that time period, they are likely doing hundreds of surgical procedures, many different procedures, including these that we're talking about today. But the numbers there are just far larger than the minimum requirements. And I apologize, I only got invited yesterday. The last time I looked at the bill, the minimum requirements was only two per procedure. And I know the gentleman before me was talking about minimum requirements of four and five. I can tell you from my residency colleagues that they are doing hundreds of surgical procedures on the eyeball. So I think that our opinion as the board, again, looking at quality and safety as our primary determinant, once we could not find any benefit from cost or access, we felt that the preponderance of the evidence would be to vote against this and to oppose this bill. And I will add that that has been a unanimous decision on multiple times that we have looked at this. So that was the opinion of the board. I'm happy to answer any questions. Again, I don't do the procedures, I can't answer technical details, but I'm happy to address either our conversations or any of my past experience or whatever you may have.

[Representative Chea Waters Evans (Ranking Member)]: So I have three children and my youngest is 15, and I'm teaching him how to drive. It's the last one, thank God, because it's harrowing

[Dr. Danielle Phillips, OD]: right there with

[Representative Chea Waters Evans (Ranking Member)]: you. Oh, gosh.

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: I'm on two of three.

[Representative Chea Waters Evans (Ranking Member)]: Oh, gosh. Yeah, this last one's really a he's a treasure. So here's what I'm saying is that over he's getting his license in a few right? And it's terrifying at first when you first do this, when he's first driving this car, even though he's driven things around our property or, you know what mean? He can drive a golf cart, he can like do all this other stuff. You get in a car and you get on the road and it's scary for me anyway, not him necessarily. But and then I was thinking this morning as he's driving to school and he's been doing this pretty consistently over the last year, I was thinking about it in this context, which is that. He seems more confident. He seems more relaxed. He seems like he's making some really good decisions. And it's because he's had forty hours of required driving, more than the forty hours they require to get your driver's license. Granted, he's not like an adult who's gone to school to train to be an optometrist, but just bear with me. It's because he's had all of this time. He had the the class, he took the driver's side, he learned the science, he did all this stuff. And my hesitation when it comes to this is what you just Can you talk a little more about the training? Because that's where I really get stuck. Because I feel like the more you do something, the more comfortable you feel, the less opportunity there is for mistakes. And as people, as it's been mentioned a lot of times, we don't know a lot in this committee necessarily about medical procedures and stuff. So we only know. Sort of the licensing and training aspect of it is what I see is coming in our jurisdiction, right? Because that's we do things with our PR a lot and and trust them, by the way, you know, you trust their judgment and all this stuff. So can you help me connect all of this?

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: I think you have a great analogy, right? It's like learning any skill. Obviously, the dangers associated with it may change. Driving is actually a really dangerous skill that you learn. But how do you learn? You learn by driving with somebody. So you're in that car with him for that extended period of time, and you get to assess whether or not he is ready to test or he's ready to practice on his own. And if you don't think so, you drive with him more, right? And there's a certain minimum that you're getting to in a certain level, and then you're testing. And what I guess I would say is that what we know is that ophthalmology residency has proven itself to have an adequate level of training. And that number, forty hours is the analogy, in residency is much higher than what most optometry schools are teaching. Now, may be some variability and these things are constantly ongoing change, but the amount pure hours involved is so much higher for an ophthalmologist than an optometrist. And with those numbers comes practice. Now, will an optometrist, I mean, somebody may be exceptionally gifted and they know the procedure after one, but will all of them? And is two enough? And well, if two isn't quite enough, do we really want them learning as they're doing procedures here without an ophthalmologist or somebody sitting over their shoulder? So it's really about that training while you're being observed. I mean, all of us can learn things and we'll get better with them the more we do them. But do we want that training period to be while you're observed with somebody over your shoulder that has all the experience and that can jump in if something's going wrong? And I just think the numbers for an ophthalmology residency really support that. And these procedures being done by optometrists have not been around that long. There's very little malpractice data out there. We all know that it takes five to seven years for most malpractice cases to go through the system. So not that malpractice should be a measure of safety or quality, but it is one thing that we look at. So, we haven't had enough time to know, and we just felt uncomfortable with the stark difference in numbers and hours of training that we would prefer to not be the first, not be the second, but not be the last to make these changes, and wait and see how things go. And are there actually improvements in quality? Are there actually improvements in access and cost? And it would be nice to see that data before we make the change. I don't know if that totally answers your question, but it really, again, for us, it came down to the amount of hours in training and the number of procedures.

[Representative White]: That was helpful. Thank you.

[Representative Matthew Birong (Chair)]: Representative Stone.

[Representative Mary-Katherine Stone (Member)]: Hi, I was wondering, could you talk about the difference in between overseeing surgery and specialty care versus current optometric scope? And then also you talked a little bit about the makeup of the board. I was wondering if you could also talk about how y'all make decisions on issues.

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: So the first question was about I'm sorry, could you phrase that again? First question.

[Representative Mary-Katherine Stone (Member)]: What is the difference between overseeing surgery and specialty care, like ophthalmology, versus current optometric scope? Could you just go over the difference in oversight as it currently stands?

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: Guess I would say is that I'm not an optometrist and I don't know the full scope, but they're not doing, my understanding is at this point, they're not doing invasive procedures. Whenever we jump from non invasive to invasive, the level of supervision greatly increases. And that's in any training program, at least in medicine. So when you start going from doing a physical exam to doing surgery, you might be allowed to do a physical exam far before you're allowed to do a surgery, and then certainly long before you don't have many people looking over you. As far as the exact specifics of the optometry scope, that's a little outside of my knowledge base. Is that what you're looking for?

[Representative Mary-Katherine Stone (Member)]: So, right now, there's a difference in oversight, is what it sounds like. And I was wondering, do you think it would be consistent with the oversight authority of the BMP to oversee these procedures if this bill passes and it goes through just to provide?

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: Are you asking if the board would be overseeing these? Optometry falls under OPR, we have no jurisdiction over Even if the optometrist started doing surgical procedures that would normally fall under an ophthalmologist, we do not have any jurisdiction over optometry licenses.

[Representative Mary-Katherine Stone (Member)]: Okay. I can ask Ledge Council to see, but I'm wondering if we should give you that authority if we go this route just because you are currently overseeing ophthalmologists, medical doctors who do these procedures.

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: Correct. I will say that not speaking for the board, my own personal comment here is that I am finding I've been on the board now, I think this is my fourth year. It is a little confusing how the regulation is set in this state. And if there was some clarification, I think it would be great. I think right now we treat nurse practitioners and PAs very similar, but we have authority over PAs and not nurse practitioners, even if they're doing the exact same procedures. Similarly, there's a separate board for DOs who could be ophthalmologists as well, or any other specialty, but that is, again, under OPR. So who follows under OPR, whether it's optometry board of nursing, nurse practitioners, nurse anesthetists, DOs, etcetera, versus who falls under the Vermont Board of Medical Practice is frankly confusing and disjointed in my opinion, but that's long preceded my involvement of the board.

[Dr. Danielle Phillips, OD]: Any other questions?

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: Did address your questions?

[Representative Mary-Katherine Stone (Member)]: Right. I know. Yeah, it's totally confusing and I agree. So I was just wondering if you think would it make sense for the BMP to oversee these procedures to help kind of make it less confusing?

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: It potentially could be beneficial. Mean, we would be treating people doing the same things in an equal manner.

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

[Dr. Danielle Phillips, OD]: For our guests. Nope. Thank you so

[Representative Matthew Birong (Chair)]: much for the time, sir. Thank you. I'll give the input. Final witness for the morning joining us via Zoom, we have Jennifer Lindsay, MD, MBA Associate Chief of Education, Massachusetts Eye and Ear Institute Director of Residency Training Program, Harvard, ophthalmology. Good morning, Scott. Welcome.

[Dr. Jennifer Lindsay, MD, MBA (Vice Chair for Education, Mass Eye and Ear; Residency Program Director, Harvard Ophthalmology)]: Thank you. Good morning, everyone. I'm really honored to be here to speak with you. You are making a critically important decision that will affect the health and safety of the citizens of Vermont. I want to thank you for considering all aspects of the issue and for taking the time to hear what I have to say. My name is Jennifer Lindsey and I serve as the Residency Program Director for Ophthalmology and Vice Chair for Education at Mass Eye and Ear. I'm a practicing comprehensive ophthalmologist and clinical and surgical teacher for Harvard Medical students and residents. I've been an educator and a practicing clinician for over twenty years and have served on the faculty of Baylor College of Medicine where I trained at Vanderbilt, where I was residency program director for six years, and now at Mass Eye and Ear. As program director, I'm responsible for the training supervision and ultimate certification of the next generation of eye surgeons. I want to begin by stating clearly that I have immense respect for our optometric colleagues. They are vital partners in primary eye care and our healthcare system functions best when we work together. However, I'm here today to express grave concerns regarding S-sixty four, a bill that would expand the scope of Vermont optometrists to include eye surgery and to clear up some misinformation that you may have heard regarding ophthalmology education and training. Surgery, whether performed with a scalpel or a laser requires a level of clinical judgment and hands on experiment experience that is fundamentally different from primary eye care. As a program director and comprehensive ophthalmologist, I'm intimately familiar with the high standards of ophthalmology training. The path to becoming an ophthalmologist is rigorous. After four years of medical school, we complete a minimum of four additional years of intensive surgical residency. We've heard our optometry colleagues question the value of medical school for eye care. You heard recently from Delaney Curran, an ophthalmology resident about medical training. I'd like to add some more detail here. Doctor. Feiss and her testimony stated that only a few hours are devoted to ophthalmology and med school. This is a misrepresentation. Most medical student schools devote the first year and a half to lectures, conferences, case based learning, book learning. It's true that most medical schools require few hours of ophthalmology during this time. It may be the case that some of this is taught by optometrists in Arizona, but I can assure you that this is not the standard elsewhere and that expert ophthalmologists are the primary faculty providing this teaching at the vast majority of medical schools. Beyond the classroom, much more time is devoted to ophthalmology during the clinical years. As you all know, students can go into many careers after medical school from primary care to brain surgery. In addition to the core clinical experiences like internal medicine, psychiatry, general surgery, students have a great deal of flexibility with elective rotations where they can explore specialties of interest to them. Many students take two weeks of ophthalmology during their general surgery block, and those with continued interest in the specialty will often do two to four months of additional clinical rotations. This is where they're working with expert faculty, learning to perform the eye exam, coming up with a list of possible diagnosis for the patient, determining what tests are needed to narrow down that list and formulating a plan for how the patient should be treated. Faculty ophthalmologists guide them through this process to hone their skills. Residency programs in ophthalmology receive about 600 or 700 applications every year for three to nine residency positions. I can tell you that an applicant who had not completed these two to four months of additional ophthalmology electives would not even be considered for a position in our program. Some students even take an additional year of training to pursue research in ophthalmology to better understand the field. I'd also like to provide more detail about residency training. Residents receive five to ten hours per week of lectures and conferences. In addition, they have multiple simulation sessions where they learn the fundamentals of eye procedures and surgeries in a controlled environment under the expert guidance of trained surgeons. After demonstrating skill on the simulator and in the wet lab, they're allowed to move on to performing parts of procedures on patients, again, under the direct supervision of expert faculty surgeons. When they master a step in the procedure, they're allowed to progress to the next step. This graduated autonomy is fundamental to ophthalmology surgical training and assures patient safety during the learning process. During our four years of hands on surgical training, we don't just learn how to do a procedure, we learn the complex anatomy of the eye, how to manage complications, and importantly, when not to operate. By the time an ophthalmologist is allowed to practice independently, they've spent thousands of hours in direct supervised patients care. This is not a gap that can be bridged by a weekend course or a few classroom sessions. I'm also responsible for making sure that my residency program is compliant with the standards of our accrediting body, the ACGME. There's often a misunderstanding as we heard from Doctor. Hall regarding the ACGME minimum surgical requirements. You may hear these numbers cited as proof of readiness, but it's critical to understand what those numbers actually mean. Requirements are not competence. These minimums are simply a floor and are evaluated in aggregate to assure that a residency program provides enough volume for a diverse education. Taken together, the minimum requirements represent hundreds of procedures over the course of residency training. Our residents often graduate with more than 700 procedures in total. Reaching a minimum number does not grant the resident a right to perform the surgery. Competence is determined by a committee of expert faculty surgeons led by the program director. The Clinical Competency Committee or CCC includes faculty surgeons who have been in practice and teaching for years, many of whom have completed one to two additional years of fellowship training in such areas as cornea, retina, pediatrics, and glaucoma surgery. During four years of residency, residents rotate through many subspecialties as well as multiple blocks of comprehensive ophthalmology. At the end of each block, faculty complete a rigorous detailed evaluation where they rate multiple aspects of the residents performance from patient exams to procedures, communication and professionalism, just to name a few. All of these evaluations, as well as verbal feedback from key faculty, detailed evaluations of individual surgical procedures, and results of rigorous annual in service exams are diligently reviewed by CCC members every six months and more often as needed to determine if a resident is meeting expectation and is ready to move on to the next step of training. Mastering safe and effective eye surgery requires extensive practice under close supervision. We review hundreds of procedures performed by each resident. We look for technical precision and more importantly, surgical judgment. We do not sign off on a surgeon until we are certain they can safely handle a patient's vision. Claims have been made that the Accreditation Council for Optometric Education ensures graduates are ready for these procedures. I ask you to consider the logic of that claim. How can a student be trained to perform a procedure that is illegal in the very state where their school is located? The vast majority of states where optometry schools exist, these surgeries are not permitted. Consequently, training consists of short courses, sometimes as little as thirty two hours of instructions, simulations using plastic models or virtual lasers, and a lack of human experience. Many graduates have never performed these procedures on a living, breathing human being under the guidance of a surgeon. A simulated eye does not bleed, it does not move, it does not have complications. You can't learn surgery in a classroom. You learn it at the bedside and in the operating room. What do students do then in states where patient safety standards are upheld and surgery is outside the scope of optometry? Doctor. Feist told you that these students have the option to travel to one of the three states where optometry schools are based that allow these procedures. It's clear that these three states would not have the capacity to train every optometry student from 25 schools in the country. At most, they may provide a select few students with hands on experience on a few patients. Optometric education is not standardized and in no way sufficiently prepares someone to perform safe eye surgery. The eye is a beautiful, complex, delicate organ that provides us with our most precious sense, sight. I liken it to the heart, another complex and delicate organ that provides us with life itself. Would you want your heart surgery performed by someone who had not been to medical school, who had only practiced surgery on model hearts that don't bleed, or at best had done four or five surgeries on live patients? I don't think so. Your eyes and the eyes of all Vermonters are just as valuable and deserve safe surgery by a trained medical doctor. There's no such thing as minor eye surgery. The term laser surgery sounds clean and simple, but a laser is a powerful surgical tool. If a laser is fired just a fraction of a millimeter off target, it can cause permanent blind spots, hemorrhages, or cataracts. Performing a laser surgery when it's not needed can cause inflammation of the eye, worsening of disease, and can delay accurate diagnosis and proper care. Similarly, incisional surgery on the eyelid involves delicate structures that protect the eye. One mistake can lead to chronic pain, infection, or loss of sight. The citizens of Vermont deserve to know that when a surgeon approaches their eyes, that individual has the full weight of medical and surgical residency training behind them. We all want to increase access to care, but we must not do so by lowering the standard of safety. There's no substitute for the years of medical and surgical training required to safely operate on the human eye. I urge you to vote against this bill and keep surgical eye care in the hands of those specifically trained to provide it. Thank you and I'm happy to answer any questions.

[Representative Matthew Birong (Chair)]: Thank you. Rep. Waters Evans.

[Representative Chea Waters Evans (Ranking Member)]: Hi, can you When we're thinking about access and cost and expanding these surgeries to people who are currently optometrists, they have an office, they have equipment, Is this equipment that they would need to be able to do these surgeries and the sort of physical aspect of their office and the staff that they would need to start doing these surgeries. Can you talk about that and what I know that cost varies wildly, like, know, let's say you were just a rural optometrist and you wanted to add this to your practice, can you talk us through what you would need materially and staff wise and what that could look like cost wise? Absolutely, thank you for the question. I think at minimum you would need a room that is safe for a laser and that often involves kind

[Dr. Jennifer Lindsay, MD, MBA (Vice Chair for Education, Mass Eye and Ear; Residency Program Director, Harvard Ophthalmology)]: of reinforcing the room with materials that the laser cannot penetrate. And that would probably add costs. I would imagine that most optometrist offices do not have laser safe rooms. They have to be built specifically for that. The lasers themselves range in costs from 25,000 to hundreds of thousands of dollars. And then you also need a process in place to be able to adequately clean the lenses. So if you're using a laser, often you'll have to apply a lens directly to the patient's eye to be able to deliver the laser to the correct part of the tissue. Those lenses have to be cleaned very strictly by instructions from the manufacturer, and that can often require a sterilization hood or specific chemicals. They have to be processed in a very specific way. And so, this is a process that would add cost to the overall provision of the lasers. Probably it would not require a lot of additional staffing because usually our technicians that help us in ophthalmology and optometry are able to help with the lasers as long as they have appropriate training in assisting.

[Representative Chea Waters Evans (Ranking Member)]: I know nothing about this, so sorry if my questions are silly, I but don't know. When when an optometrist gets trained to do the surgery, are they also trained in how to clean that lens? Or is this something that's a training that's done by the person from whom they buy the equipment? Like, how does that work?

[Dr. Jennifer Lindsay, MD, MBA (Vice Chair for Education, Mass Eye and Ear; Residency Program Director, Harvard Ophthalmology)]: I think it would vary, you know, if you have a good support staff, your technicians can be responsible for cleaning the lenses and they could get that training from the manufacturers. If an optometrist were trying to do this on their own and they don't have a lot of support staff, then certainly they would need to get that training as well. I

[Representative Chea Waters Evans (Ranking Member)]: think the answer is yes, because it's a machine. If something goes wrong with a laser that you're using for eye surgery, how do you know before Absolutely, you put it in someone's

[Dr. Jennifer Lindsay, MD, MBA (Vice Chair for Education, Mass Eye and Ear; Residency Program Director, Harvard Ophthalmology)]: this is a great question. Most of the lasers do have internal checks to kind of alert you if something is wrong. They'll have a warning sign that flashes up, but it's very, very important that the doctor is familiar with the laser. Our doctors, even those of us that have been in practice for twenty years like me, I have to do laser safety training every single year to make sure that I maintain those competencies and that I know the hazards of the laser and how it can go wrong. And a tricky thing about many of the lasers is that they have multiple settings. And so you have to make sure that you're on absolutely the right setting. And if there's one switch that you can flip, there's a laser that does SLT and YAG. And if you are trying to do YAG and you put it on the SLT setting, you can blind a patient. And we've seen that happen in Kentucky with optometry. And so, I think, you know, you really have to be very well educated in the use of these lasers and know the potential dangers.

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

[Representative Matthew Birong (Chair)]: Presenter.

[Representative Mary-Katherine Stone (Member)]: I was wondering too, if Vermont expands the scope and requires optometrists to, or like allows them to do this, would that require them to carry additional malpractice insurance?

[Dr. Jennifer Lindsay, MD, MBA (Vice Chair for Education, Mass Eye and Ear; Residency Program Director, Harvard Ophthalmology)]: I'm not familiar with optometric malpractice insurance. I unfortunately can't answer that question, but I'd be happy to look into it and get back with you.

[Representative Mary-Katherine Stone (Member)]: Yeah, I think that's important to you when we're thinking about cost. I'm anticipating you probably would need to.

[Dr. Jennifer Lindsay, MD, MBA (Vice Chair for Education, Mass Eye and Ear; Residency Program Director, Harvard Ophthalmology)]: Absolutely, yeah. I would guess that you would because I know we do as eye surgeons.

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: Thank you. Judging by the

[Representative Matthew Birong (Chair)]: hands and motions in the gallery, we may have a guest who can answer that question.

[Dr. Jennifer Lindsay, MD, MBA (Vice Chair for Education, Mass Eye and Ear; Residency Program Director, Harvard Ophthalmology)]: Great, thank you.

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: Doctor. Dean Barsell, I'm an optometrist. Our insurance or liability insurance that we're required to have actually are a pharmacist. Most optometric malpractice insurance policies cover what is within the scope of practice for optometrists. And we've submitted letters to this effect and I can submit one to you if you'd like, but that's an easy answer.

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: Thank you.

[Representative Matthew Birong (Chair)]: Any other questions for our guests? Thank

[Representative Kate Nugent (Member)]: you. I'm just wondering if you think that medical school is necessary to do these procedures just bar none, or if there is some kind of training or experience that you would think would be okay for optometrists to receive to carry out these procedures?

[Dr. Jennifer Lindsay, MD, MBA (Vice Chair for Education, Mass Eye and Ear; Residency Program Director, Harvard Ophthalmology)]: The short answer is yes. Think that medical school is absolutely necessary. And I think that optometrists could go to medical school and do residency, to be able to safely perform these procedures. The reason that I think medical school is necessary is that it provides that robust foundation of understanding diseases and the whole body and the whole patient and knowing about inflammation, infection, cancer, learning all of those things so that when a patient comes to you, you can see how the disease in the eye relates to their whole body and how it's affected by everything that's going on with them as an entire human and not just the eye.

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: Thank you.

[Representative Matthew Birong (Chair)]: Anything else for our final guests before we move on to our final item today, which is also an OBR conversation.

[Representative White]: Thank you.

[Representative Matthew Birong (Chair)]: Seeing none. No, thank you all so much for the time.

[Dr. Jennifer Lindsay, MD, MBA (Vice Chair for Education, Mass Eye and Ear; Residency Program Director, Harvard Ophthalmology)]: Thank you again for the opportunity.

[Dr. Danielle Phillips, OD]: We'll definitely be speaking to

[Representative Matthew Birong (Chair)]: this bill more next week. One more hand from the gallery, yes.

[Representative White]: Doctor. Barslow was here to testify.

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: Oh, I didn't know. Oh, I'm sorry. As well as

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: Dan. Okay.

[Representative Lisa Hango (Vice Chair)]: Yes, please. I can interrupt for a second. I had questioned that earlier and there was a scheduling thing where they yielded their time to others. So if we don't have any specific questions for them, they're no longer on schedule to testify. But if they wish to testify, that's up to your chair.

[Representative Matthew Birong (Chair)]: I am fine with the testimony. The other item is not a necessary thing to do today. We can easily do that tomorrow, as that bill is in the in between chambers. Please, sir. Yes.

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: I'm Doctor. Dean Barsoille. I'm the immediate past president of the Ra Optometric Association. I can read the room and maybe Dan and I would just testify to you together. That would be fine.

[Representative Lisa Hango (Vice Chair)]: And our committee assistant has your information so you can post it.

[Dr. Danielle Phillips, OD]: So I'm Doctor. Danielle Phillips. I practice up in St. Alden, Vermont. I've been in touch with Representative Hango since I got here in July. Went to the University of California Berkeley School of Optometry and I did my residency in Oklahoma under Doctor. Nate Leitheizer, who you've heard from before. And I have not only done every one of these procedures, I've taught them clinically to two cohorts of students, both in pre clinic and directly supervising their pre clinic exams to be able to see live patients and

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: over live patients as well. So for a couple of years, my father sat on the Royalton Select Board, and his pet peeve was people coming in and saying the same thing over and over again. So, I have a couple of pages of prepared statement, but it seems to me that maybe we should just answer questions that the committee has and then get out of your hair. And I've written some of them down that I'd be happy to address that the committee has asked, but if you have specific questions for Vermont optometrists, I'm happy to do that first.

[Representative Matthew Birong (Chair)]: I mean, prepared the statement. I mean, feel free to speak to it.

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: I can send it to you and you guys can all read. Very fair. So, then let me just go through a little potpourri here of things that I've collected this morning. One of the questions that's been asked is, How does an optometry student in a school of optometry in a state that does not allow these procedures get hands on experience? So the one that hasn't been mentioned, I think, important, is remember that VA is federal property, and you to the highest level of a license for everything except lasers. And that was a finding in OPR's report, and VA is actively working on changing that. But as far as injections, as far as chalicean removal, that kind of stuff, I I did that back in 2009 when I did my residency in White River Junction, Vermont. So that is a big area, and you could ask an educator who knows better than I, but I believe that every school in College of Optometry requires students to rotate through a VA facility. There's been a lot of on call discussion. That is interesting to me. My office has somebody on call twenty four hours a day, all the time. The local ER has a problem. They call me. I'm the person that Gifford calls when they have trouble with eyes and they need somebody to see it. I think it's a little bit of, and it's been represented today, and I just want to make clear, ophthalmology tends to go into specialty tracts. And so, just because you have an ophthalmologist who is performing one of these procedures, a laser procedure, does not necessarily mean that ophthalmologist would be equipped to deal with complications. They also have to have a role of people who are on call to deal with it. So, for example, if there's a retinal detachment, as was mentioned before, the person who has that complication during the surgery is not necessarily the person who is going to be covering it. Not all ophthalmologists take call all the time, and I have a deeply personal story on that. I will leave that to say, if you're in private practice, there are times where private practice does not have somebody on call to cover patients. Thirdly, I believe it is the case for all of my insurance contracts, but insurance contracts, when you sign up with Blue Cross or MVP, they require you to have an on call plan to be available to your patients. We talked a little bit about the Board of Medical Practice voting on this, and they have talked a number of times about optometry performing these procedures. Both the Board of Medical Practice and OPR are responsible for protecting the safety of the public. But I would just like to point out, one of them spent days generating a two fifty eight page report. I have spent more time with OPR staff than they would like, going through this process, answering questions, running down leads, getting schools and colleges optometry who were very reluctant to provide information to get it to them. Has been a task. They also mentioned that malpractice claims take five years to adjudicate. And I'll remind this committee, I sat here in 2019 with this committee being the first one that we talked about scope expansion. So 2019 to 2026, if there was a flood of malpractice claims available, that's the timeframe. Be happy if you want to throw something in. Guess I figured we'd answer questions and be done.

[Representative Matthew Birong (Chair)]: Two hands right now. Go for it. Reporters Evans and Rep Stone.

[Representative Chea Waters Evans (Ranking Member)]: Rep Stone had her hand raised first. Okay. Stone and Rep Simmons.

[Representative Mary-Katherine Stone (Member)]: Thank you. I just wanted to go back to what you were saying about the VA. First of all, is it a national accreditation requirement or is that common practice? And if it is an accreditation requirement, can you point us to the accrediting standard that would require every optometry student to complete the VA rotation?

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: Yeah. I'm practicing Vermont optometrist, and I don't have a lot of background in that education. There is a section in the report that talks about VA, and OPR went through that, but I couldn't tell you one way or the other.

[Representative Mary-Katherine Stone (Member)]: Okay. Just

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: I don't know any student that's not gone through a VA.

[Representative Mary-Katherine Stone (Member)]: Okay. But I'm looking, and I just wondered if I think it's important to clarify if it's many students do this versus every school requires this. So it would be helpful if you could point us to an accrediting standard.

[Dr. Danielle Phillips, OD]: So I can answer this, but it definitely is not required that if you VA, I know students that went to my school that didn't I graduated in 2020, so I'm a little more I did do two VA rotations at the Portland VA Hospital in Portland, Oregon and one at the VA Hospital in Skokie, Oklahoma, but that was part of my decision. Route I was going to optometry, My background is really in ocular disease. There are people who do were going around in binocular vision or pediatrics that will choose to go in a different route to specialize in specific areas. So definitely, you don't have to, but definitely at the University of California Berkeley, we highly encourage at least one rotation, but not required.

[Representative Chea Waters Evans (Ranking Member)]: Thank you so much. Just

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: to come back to that too, every school trains up to a level. That was the finding of the OPR report, that if you graduate before 2019, you had to go back and do some didactic stuff to obtain this endorsement. If you graduate after 2019, every single school covers these procedures at minimum in classroom and in lab. The reason that OPR said that there had to be proctored examination, that there had to be a third party evaluating these procedures in the form of national boards, and the reason that you have to have minimum procedures is to standardize that across the tape. You can rest assured that that is going to provide the safety that you guys seek.

[Representative Chea Waters Evans (Ranking Member)]: Oh, is it my turn? Sorry.

[Representative Matthew Birong (Chair)]: I got

[Dr. Danielle Phillips, OD]: Laura, let me step away.

[Representative Chea Waters Evans (Ranking Member)]: All right. I just when you said it was difficult to, if you were chasing down information that people were reluctant to provide, why are they reluctant to provide information about these topics? Do you have any idea?

[Representative Kate Nugent (Member)]: I

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: think there are 22 schools. They didn't know what Vermont was doing, so they kind of got this request. They didn't know the requester, and the request said, Please send us all your coursework. And I think for many of those schools, that got lost. I assume everybody in this room is familiar with the fact that in early twenty twenty, OPR issued a report that said, We actually don't think that optometry should be doing this. We don't have the information that we need for this. And that's been, from 2020 to 2023, was three years of going back through and kicking over all the rocks and getting all that information.

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: Okay. Thank you. Representative White?

[Representative White]: Can you speak to the language in our bill right now? Currently demonstrating competency, it would be at least eight hours of supervised clinical training, and then we lay out different procedures that they need to complete at least two of all supervised. To me, that seems awfully low from an outsider's view. And especially looking at this chart that you provided us as well, it seems like other states require a lot more.

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: So I sent a chart this morning. If you look through, many of the states require the thirty two hour didactic course, and then they are licensed to provide laser procedures. If you glance through it, you'll see. Not every state is like that. Some of them require that somebody watch you do one. I think Kentucky, you have to do one SLT and one YAG, but it's in the breakout that I say. You asked a long question. That was a short answer. Is there something that I didn't cover?

[Representative White]: No, it's fine. Thank you.

[Dr. Danielle Phillips, OD]: So we've talked a lot about training and lasers and stuff. But let's so just breaking down lasers just by themselves. So we're looking for three primary care laser procedures that we that is especially necessary, at least to my people in Franklin County, the SLT. So the rate limiting steps behind these procedures are really slit lamp and gonioscopy. Slit lamp is something that every optometrist

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: With a microscope.

[Dr. Danielle Phillips, OD]: Yeah. Oh, the microscope on the table that we used to look at eyes. So I began learning that on my first week of, school and perfected it throughout my four years. Gonioscopy, began perfecting it my second year. These are the foundational parts. I do not perform gonioscopy on every single patient, but I perform a slit lamp exam on every single patient. So what I am examining when we're talking, let's talk about the yag capsulotomy, every single comprehensive exam I am examining the back of the lens of every single patient I am looking at, and obviously you would only do a yag on somebody who's had cataract surgery, so that's the lenses of people that have cataract surgery. So you are focusing a laser with pinpoint accuracy that has a offset that if even you miss this piece of tissue that you've been looking at for four years of optometry school and every single day that you practice, you're you're basically basically, if you were giving a presentation in a lecture hall, the simple this would just be adding a laser pointer to point at the thing that you are looking at every single day. Same with the iris. That's the LPI. You are looking at a piece of tissue. You look at it every single patient, every single day, all the way through optometry school. And the SLT, which is a different setting, you're looking through a gonio lens at the corner of the eye. That laser only reacts when it hits pigment. If you basically if you miss your spot, it does nothing. If you hit the trabecular meshwork, the only thing it's gonna hit is the pigment that you were trying to treat. And yeah, it is Yeah, the trig What's that? Straightforward. Yeah, to a point that we would be qualified to do cataract surgery or heart surgery or something would just be insane. These are not the same level of procedure. These are things that I didn't see patients today. So in three days today, I referred five SLTs, two YAGs, and that's just from Monday to Wednesday. These are patients that I've sent from St. Albans to Burlington, and it's I can fast track them and get a high risk patient in within a month, but most of them are taking about three months to get in. And every one of those patients has to be re dilated again. Anybody who's doing radiance of laser surgery has to evaluate the retina. So I've already evaluated the retina, but every surgeon is going want to reevaluate that retina. So they have to make a drive down to get dilated, go back to Franklin County, then you cannot do an SLT and dilate it, then you have to come back for an additional appointment. So this is something that I've trained in, I've done countless numbers of time, and it is the best way of treating the best first line treatment for glaucoma. And And I will keep sending them to Burlington because this is the best thing for my patients.

[Representative Matthew Birong (Chair)]: Perhaps, Billy?

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: You mentioned the laser not reacting to a neutral tissue. The laser is preprogrammed, it's best.

[Dr. Danielle Phillips, OD]: So, like doctor Lindsay was saying, there are two settings on the laser. So one is designed to treat the trabecular meshwork, basically clear up the drainage, allow the pressure to go down. That one only reacts to pigments. So basically, you point it at the trabecular meshwork, a thing that you look at every day, push a button, and it reacts. If you don't hit the pigment, it does nothing. The other one is pinpoint focus, it does react on tissue, but it has a built in setting to basically offset it. So if you are a little off, it just goes inside your vitreous and does nothing. There are these horror stories. One of my patients pulled out a phone yesterday. He's like, have you seen this thing on Vermont Digger that whatever. It is this horror story that we were it is so seldom that this happens because this is going back to 2016. Somebody did it on the did the wrong setting on the wrong patient. Basically, they went through 10 steps of checks that they just ignored. It's a horror story. It's like somebody getting their driver's license and then just driving into a crowd of people, basically. Yeah. It was so absurd even as an optometry student to see how somebody could do this. And this is pretty much one of the two out of hundred and forty thousand documented cases that this has happened. And every optometry student is, here's this story. And every optometry school across the country is like, how could that possibly happen? So

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: And it happens in the fields of care. There's always one story Yeah.

[Dr. Danielle Phillips, OD]: That tries to set up for a mistake. Levels of negligence that happen consecutively in a row. Exactly. Thank you so much. Yeah.

[Representative Matthew Birong (Chair)]: Rep Stone, Bennington.

[Representative Mary-Katherine Stone (Member)]: Hi. So would you agree that the issue isn't whether a laser can target the tissue, but whether the practitioner has the training to recognize if there are contraindications or to manage those adverse outcomes. I'm just thinking like, if these procedures are effectively risk free, then why are they considered procedures at all rather than routine screenings?

[Dr. Danielle Phillips, OD]: So nothing we do, any procedure we do is risk free. So the major things that happen with a laser procedure, inflammation that we treat daily, spike in eye pressure that we measure before and after a patient leaves and treat, and it is a transient spike in eye pressure. Things like retinal detachments and perforated corneas, these aren't really generally things associated with laser surgery, but these are things that we are constantly monitoring on patients every day. And just like a general ophthalmologist can't treat them, we will send a retinal detachment to a retina specialist and we will send a perforated cornea to a do we call it? Cornea specialist. Yeah. But most other things I can manage and monitor my own clinic. I have the exact same diagnostic equipment both for the cornea and the retina, as a retina specialist does and a corneal specialist does.

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: I would add to that, that we're the ones who are sending patients to ophthalmology when they need these procedures. We're the ones receiving them back and often managing the postoperative complications already.

[Representative Mary-Katherine Stone (Member)]: But you can confirm that

[Representative Chea Waters Evans (Ranking Member)]: the risks

[Representative Mary-Katherine Stone (Member)]: that you just mentioned, like the elevated intraocular pressure, retinal injury, corneal injury, unintended tissue damage, those are known complications of the laser procedures.

[Dr. Danielle Phillips, OD]: Those kind of things I'm managing with multiple conditions on a daily basis for all my patients.

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: Right, but it's

[Representative Mary-Katherine Stone (Member)]: not to be using a laser, it's still a risk that those

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: Those things risks exist for the patient because they're having the procedure. I mean, it would exist for the patient if an ophthalmologist was doing the procedure as well. It isn't that ophthalmology has no risk and optometry suddenly has risk.

[Dr. Danielle Phillips, OD]: And these are extremely low risk, like extremely low risks. I mean, I have done and supervised people on their first time doing these procedures. It is this is not something that inflammation happens. Eye pressure is patient dependent, but we are managing eye pressure on every patient. We take eye pressure on every single patient every single day. So a spike in eye pressure is something that I'm managing on patients that have nothing to do with. Yeah, and like I said, tissue damage, it's not really if you're doing the procedure correctly and you have proficiency in the slit lamp and an understanding of how to use your lens, it's not something that even really would happen.

[Representative Mary-Katherine Stone (Member)]: Okay. So sorry. Final question, but I just keep going back to the training. So I'm hearing that these procedures are usually, like, simple, low risk. So why then looking at all the charts and stuff that we've been giving, why does ophthalmology training devote so much time to learning about complication management, patient selection, procedural judgment?

[Dr. Danielle Phillips, OD]: So when an ophthalmologist first started managing eye condition, they started their first day of residency. By the time I started my first day of residency, I had four years of managing eye conditions. So to say that we don't have training would be inaccurate.

[Representative Mary-Katherine Stone (Member)]: No, I didn't mean, I didn't wasn't saying that you didn't have training. I'm just wondering, like, if it's misdiagnosed before the procedure and then they have, like, an underlying issue that presents as something else.

[Dr. Danielle Phillips, OD]: Oh, so, I mean, there there is a list of things, but you so like I said, you have to check the retina for any risks of so the old lasers that they used to use, they use a different form now. But in these old testing, they used to use a more kind of select instrument of a laser that, in very rare conditions had could trigger a retinal detachment. The new lasers, the updated technology, that is almost, you know, unheard of of it happening, but we still treat every single patient as if that is a possibility. So we look at scan the retina of every single patient to see if there are any risks. And if there are any risks, then we send them to a retinal specialist before we do any procedures. So if they had a tear in the corner of their retina, we would then send them to the Retina Consultants of Vermont. They would laser that area down, and then I would ask them for clearance before going to do the procedure.

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: Additionally, we're not asking to do everything that an ophthalmologist does, right? So when we are talking about the number of hours that an ophthalmologist spends in surgery, I mean, we're talking about cataract surgery, we're talking about eye muscle surgery, we're talking about retinal surgery, depending on their specialty. So to compare hours as apples to apples would be inappropriate.

[Dr. Danielle Phillips, OD]: And we are Sorry. I was just going to say, we have a very rich relationship with ophthalmology. So this might be getting lost in all of these arguments, but I am absolutely dependent on my corneal specialist, my retina specialist, my cataract surgeons. I have their cell phone numbers in constant contact with patients. So there is this legislative battle, but the everyday life of ours, we are working together on things every single day.

[Representative Lisa Hango (Vice Chair)]: So I just have one question, and I want to go back to access because that's really important to me in Franklin County. Doctor. Phillips, you're located in St. Albans, which is in the Southern Part of Franklin County, and I am in the Northern Part of Franklin County and some of my constituents live a good forty five minutes or so depending on road conditions from St. Albans. So, the procedures that you are currently not allowed to practice, those individuals have to see an ophthalmologist and there's a long wait time for ophthalmology. We have one ophthalmologist practicing in St. Albans also.

[Dr. Danielle Phillips, OD]: Yep, Doctor. Brophy.

[Representative Lisa Hango (Vice Chair)]: Right. So, there is that forty five minute drive, again, to see that ophthalmologist. He has no partners in his office. So, if they can't get in with him, they're referred to someone in Burlington, which for my folks in the Northeastern part of the county is a good hour and a half drive in good road conditions. Many of them don't have transportation to begin with, and many of them are elderly. So that's a concern for me. So I'm not currently seeing that we don't have an access problem. And that is a big concern to me. So if this bill does not pass, and you are not allowed to perform these procedures in Vermont, and folks have to wait to get in, in either St. Albans or Burlington, what is the danger to those folks? What are these conditions that they have? What will happen if they have to wait three to The six

[Dr. Danielle Phillips, OD]: most critical one is the people with glaucoma. So glaucoma is a slow disease, but it slowly kills the nerve fibers at the optic nerve levels, slowly permanently destroying vision usually from the outside in. So if someone has glaucoma and is not receiving an eye exam and has nobody monitoring their optic nerves, generally a patient does not realize they've lost vision until all half of their peripheral vision is already permanently gone. So with those patients, the great thing about an SLT over prescribing eye drops is I can see a high risk patient that has elevated eye pressure that is in that red flag area, but I know if they have that elevated eye pressure, they most likely statistically will develop glaucoma. I can treat that with an SLT, prophylactic. SLT has virtually no side effects. It lasts two to three years, or I can treat that with a glaucoma drop. I cannot prescribe a glaucoma drop for just ocular hypertension long term. So, basically, if I see this person as potentially developing glaucoma with consistent elevated eye pressures, I will prophylactically send them to preserve their vision before they even are showing any signs of optic nerve or visual field defects, any signs that I would then diagnose as glaucoma. So for the patients that do have glaucoma that I'm sending and it's the early stages, they're extremely low risk. I can put up with two months. If they're more high risk, I can maybe put up with a month, but there are plenty of patients that I have to put on drops just while they're waiting for that appointment. Appointment. Those drops have downstream I am of the philosophy I want to keep my patients on as little medication as possible. So every medication has a balance book. There is a risk over reward thing. They are automatically deteriorating the ocular surface of the eye. You can see anytime we put fluorescein in the eye of somebody who's on glaucoma drops, you can see the damage. It's subtle damage that that is generally experienced as dry eye, but you can see the effects these drops have. They also target systems that also can can influence parts of the cardiovascular system and other things. So where these complications are not the same with an SLT. So I would prefer not to put them on drops. But if I know they have to wait three months and I'm worried, they're going on drops until they get better.

[Representative Lisa Hango (Vice Chair)]: But during that time, they're on drops. I guess this is new to me. Their optic nerve or other parts of the eye could be still deteriorating.

[Dr. Danielle Phillips, OD]: Yeah, and that's why the more high risk, the more I'm following them up on a regular basis. So somebody who I can evaluate their condition as being fairly stable, their pressures are managed well, I can see on a four to six month basis. If I am concerned, I inherited a patient from a doctor that didn't really look at the back of the eye before, probably had got glaucoma for about seven years. I am having them back two weeks, then another two weeks. I have to build up the testing to diagnose them, so I am already initiating treatment and building up testing. So

[Dr. Matthew Greenberg, MD (Chair, Vermont Board of Medical Practice)]: Thank you. Retinugent?

[Representative Kate Nugent (Member)]: My understanding, it seems like there are two, and I don't know what the right word is, protocols or standards of care for glaucoma, one from optometrists who prefer the laser treatment as a starting point, and then one from the ophthalmologist that use that as part of the treatment. I guess I'm wondering, A, am I correct on that? And B, could you speak to the outcomes for patients? Is that a fair comparison?

[Dr. Danielle Phillips, OD]: It's the newest literature that applies to both ophthalmologists and optometrists that demonstrate that SLT should be the first line treatment. There's still people that are practicing with ideas that were the previous ideas that drops were better, but now we have the clinical evidence, we are an evidence based profession, and we have the clinical evidence that should be the first line treatment. We can then add additional drops, and then in very extreme cases there's actual glaucoma surgeries that almost all cataract surgeons can do as more extreme measures. So there's multiple ways. It's basically how can we lower the pressure and keep the health and safety of the patient best in mind? And then lifestyle wise, when you don't have to put in a drop every day for the rest of your life compared to doing a procedure once every three years that has an equal effect, I would say that's what I would choose personally. But I give all my patients the choice.

[Representative Kate Nugent (Member)]: You can do both?

[Dr. Danielle Phillips, OD]: Yep, I mean, I cannot do an SLT right now, but I will refer for an SLT. I can do drops. It would be easier for me to treat them with drops in my office right then and there. And, the cost insurance for an SLT is equal to one bottle of drops of latanoprost that you will be taking every day for the next three years. So, I mean, three times 36 times the cost of an SLT to bill bill to insurance.

[Representative Kate Nugent (Member)]: Do you think the risks

[Dr. Danielle Phillips, OD]: are I would say the risks are far less. I mean They're different risks. There's it's so SLT, I'd say the side effects, the the trade off. There is virtually no trade off to an SLT where you are exposing yourself to more dry eyes, more systemic issues with any sort of medication. So We're gonna be conscious we

[Representative Matthew Birong (Chair)]: are at lunch hour. We're gonna have a very long for our interview today, so I wanna make sure folks get a solid break. Anything for our guests before we break off?

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: Thank you, guys. If you if you have any questions, if there's still lingering things, please reach out. I'm I'm happy to have a direct conversation with anybody or exchange emails. Representative Hango

[Dr. Danielle Phillips, OD]: has my email and phone number. Feel free to call me or get in touch at any time with any questions

[Dr. Dean Barsell, OD (Immediate Past President, Vermont Optometric Association)]: you just have. Appreciate it. Alright.

[Representative Matthew Birong (Chair)]: That's it for the work down here for the day, and we're gonna do a little work on tomorrow's agenda specific change, but just heads up, send out

[Dr. Danielle Phillips, OD]: an email if it does.