AS HAS OCCURRED IN THE REST OF MEDICINE, ophthalmology has been hurtling ahead for decades knowing that each year it pours forth far too many subspecialists into an already overcrowded market, based on health-care workforce needs assessments. That was the case in 1980 and in 1995 when the two most important such studies to consider eye care predicted an increasing oversupply in the ophthalmic workforce.

The net effect in other areas of medicine, dictated finally by the people controlling the purse strings—the federal government—has been a reemphasis on primary care and a shifting of the resources and reimbursement to drive that new emphasis.

Though interest in ophthalmic subspecialties and production of subspecialists has continued unabated, it goes without saying that eye care is not what it was in 1995. A Bascom Palmer group reports in July's Ophthalmology that there has been a steady increase over the past decade in subspecialty fellowship training.

While eye care has substantially changed in 10 years, so too have study models and trends analysis tools improved. What has not changed in 10 years is the 1995 RAND study's conclusion that in models in which ophthalmologists provide primary care as well as secondary and tertiary care, there is no excess of ophthalmologists, subspecialist or otherwise. But in models in which optometrists provide the bulk of primary care, there is a significant oversupply of ophthalmologists of every stripe.

And who represents ophthalmology's best claim to providing primary eye care? Not the subspecialist. Clearly, the profession undervalues the importance of the comprehensive ophthalmologist at its own peril.

It's past time to refocus the issue of supply and oversupply. A multidisciplinary effort, including representatives of and funding from ophthalmology, optometry and opticianry, through their professional associations, would be a good place to start. The option of leaving this to free market forces isn't working, and it may not be around much longer even if it were. The alternative is to let the federal regulators decide. That doesn't sound very appealing.