In rural America, opportunity for optometry amid shortfall of ophthalmologists

There are consequences for the shortage of ophthalmologists in rural America, such as inconvenience to patients and “negative outcomes,” a new study says. Optometry, though, is positively positioned to mitigate the shortcoming in care.

The study, “Geographic Distribution of US Ophthalmic Surgical Subspecialists,” was published Jan. 2 in JAMA Ophthalmology.

Its conclusions?

• Percentages of rural surgeons have declined over time.
• Female surgeons and recent medical school graduates are less likely to practice rurally.

The results suggest that the rural U.S. increasingly faces a shortage of ophthalmic subspecialty surgeons that impacts patient access to care, the study’s authors write.

“It has been established that limited access to ophthalmic care generates negative outcomes among rural or patients in underserved communities, including increased prevalence of visual impairment, diabetic retinopathy, and macular degeneration.

“As such, it is crucial that there is a rural ophthalmic subspecialist workforce available to meet rural patients’ ophthalmic needs,” they add.

AOA President Steven T. Reed, O.D., says a serious shortage of ophthalmologists can be avoided—given the number of highly trained and well-educated doctors of optometry.

“The distribution of doctors of optometry across rural America is a high-quality and effective answer to the shortage of ophthalmologists in rural areas,” Dr. Reed says. “State laws must be updated to allow optometrists to practice what they are taught for the benefit of patients across the country, particularly rural America.

“To provide effective care, ophthalmology subspecialists should solely focus on the niche care they provide rather than duplicating services provided by optometrists,” he says.

Geographic distribution of ophthalmologists

Researchers say their aim was two-fold: assess the geographic distribution of the workforce of ophthalmology subspecialist surgeons and evaluate factors linked to rural practice.

Covering a period from 2012 through 2022, the cross-sectional study analyzed Medicare-Fee-for-Service claims of Medicare patients (65 years and older) and surgeons.

The analysis of claims was for procedures for the following subspecialties: cornea, glaucoma, oculoplastic, retina and strabismus care.

Among the other findings were:

• Surgeons practicing in urban settings outnumber those practicing in rural settings.
• The percentage of surgeons in rural settings declined: cornea surgeons by 1.3%, glaucoma by 3.3%, oculoplastic by 2.1% and retina by 0.4%.
• Per 10,000 patients, the West had the highest number of surgeons for cornea (158) and glaucoma (156); the Midwest and South the lowest number of cornea (102) and glaucoma (110) surgeons; the West with the highest number of oculoplastic surgeons (300) and the fewest in the South (196). The Northeast had the highest number of retina surgeons per 10,000 patients (54) and the South had the lowest (33). The Northeast had the most strabismus surgeons per 10,000 patients (332), with the South having the least (208).
• Across subspecialties, a higher proportion of patients (17.4%) resided in rural areas relative to surgeons (5.6%).

The ophthalmologist shortage comes as no surprise to doctors of optometry who serve in rural areas. They see it daily.

Shortage presents challenge for optometrists and patients in rural areas

Shane Foster, O.D., Ohio Optometric Foundation president, says the study confirms long-held concerns of rural optometrists like himself.

“There simply are not enough ophthalmologists to meet the demands of the rural patient population in this country,” Dr. Foster says. “In my town, patients must wait six to eight months just to get a cataract consultation, and specialty ophthalmologic care simply does not exist.

“Rural residents are certainly accustomed to the need to travel for more advanced medical care, but unfortunately many of these patients may lack the resources necessary to make that trip,” he adds. “In urban and suburban settings, patients have more options for transportation—rail, bus, taxi and ride-sharing—while those services are sparse or non-existent in many rural communities.”

The consequence is delays in care and more negative outcomes; Dr. Foster continues. With this study showing that newer graduates are significantly less likely to practice in rural areas, we can expect this shortage of rural ophthalmologic care to become even worse over the next decade, he says.

Compounding that, the rural population is growing, and states with the highest percentages of rural residents—he cited Vermont, Texas, North Carolina, Pennsylvania and Ohio—have not yet expanded their scopes of practice to allow doctors of optometry to perform procedures they have been educated to perform.

“This illustrates the urgent need to not only modernize optometric scope of practice now, but for further research on how doctors of optometry can continue to provide expanded care to these underserved and forgotten populations,” Dr. Foster says.

Rural Wyoming feels the impact of undersupply of ophthalmologists

Wyoming may be the least populated state in the nation, but it suits Roger Jordan, O.D., just fine. Dr. Jordan favors the wide vistas outside of Gillette, where he practices. He also speaks highly of the small-town atmosphere and the familiarity of faces.

Gillette is tucked in the northeast corner of Wyoming, not all that far from Montana and the borders of the Dakotas.

“We’re definitely rural,” says Dr. Jordan, who has practiced here for more than 40 years. “People are willing to drive 100 or 200 miles if they need to get their eyes checked.”

He just wishes they didn’t have to.

The practice has worked hard to attract new doctors—there are five doctors on staff now. They’d like to add more.

“We don’t have a big mall, opera or concerts, or professional sports teams,” Dr. Jordan says.

Or an ophthalmologist in town.

“The closest one is at a facility that has six or seven ophthalmologists,” he says. “Their office is 135 miles away, each way,” in Rapid Coty, South Dakota.

Those distances are inconvenient for his patients, especially his elderly patients who may require someone else to drive them due to their poor eyesight and hazardous roads in the winter.

He notes that the practice’s referral relationships work well for his patients otherwise. Still, it has not been easy to recruit new, young doctors.

“All five of us are booked out probably six months or more,” Dr. Jordan says. “There are a couple of other (optometric) offices in town besides us. But we are the biggest and busiest, and it’s a challenge to keep up with the need.”

There is a certain lure to rural living and practice. Dr. Jordan’s pitch to them?

Wyoming has a higher scope of practice and is one of 12 states, enabling its optometrists to perform some procedures in other states only ophthalmologists can do. If they like the outdoors, there’s fishing, camping and hunting. Dr. Jordan also talks about the genuineness of the locals. The practice is a fixture in the community, and he is often recognized as he moves through the community for his expertise.

“They know you’re going to be there,” Dr. Jordan says.

Optometry works to close care gap

Shane Kannarr, O.D., has practiced in Pittsburg, Kansas, located in the southeast corner of the state where the borders of Arkansas, Missouri, Kansas and Oklahoma meet.

The practice opened in 2009 and now has grown to four locations, five doctors, says Dr. Kannarr, who is from the area.

Providing a range of care in a rural community such as Pittsburg is fulfilling, he says. But it has its challenges—securing access to care for patients.

“There's really a gap in need and care that needs to be filled,” Dr. Kannarr says. “We bring in an ophthalmologist for a half day or a day a week every other week.”

Depending on the eye condition, though, patients may be driving two to three hours for care.

Dr. Kannarr foresees change ahead for eye doctors, as doctors of optometry and ophthalmologists find ways to collaborate more often for the benefit of patients. The new study resonated with him. Further, he believes strongly that expanding scope for doctors of optometry can increase access.

“Aligning both ophthalmology, optometry, and sub specialists is better for getting the best outcomes for our patients,” Dr. Kannarr says.

Read: How to avert an eye care crisis