VetInfo Digest

VetInfo Digest

November 2006

Table of Contents:

Veterinary Specialization

History

Definition

General Practitioners and Specialists

When to Refer

Sad Facts about Specialists

This Month’s Note:

A number of you have written to ask how our Cavalier King Charles Spaniel, Henry, is doing after surgery and for a more complete description of what was wrong and how it was repaired. Henry is doing very well. Today was the end of the three week period post-operatively in which we were supposed to keep him quiet. That turned out to be an impossible task but we didn’t play games with him or encourage exercise. He was happy running around on his own but he seems especially happy that we are playing games with him again now.

Henry had pulmonic stenosis. This is a narrowing of the valve between the right atrium of the heart and the pulmonary artery going to the lungs. A small catheter with an inflatable balloon was passed into Henry’s jugular vein and then the balloon was carefully positioned in the valve. It was rapidly inflated and deflated several times to enlarge the size of the valve opening. This worked very well in Henry’s case. Hopefully he will have a nearly normal life span and will be able to play and engage in exercise just like any other dog. The veterinarians at NC State did a good job of taking care of Henry.

Veterinary Specialization Historically

Veterinary medicine is undergoing changes that leave many clients confused. People are very used to seeing a general or family practice physician and being referred frequently to specialists in orthopedics, internal medicine, infectious disease or other fields. In addition, a group of specialists works behind the scenes to facilitate your physician's work such as radiologists and clinical pathologists. While you may not really be aware of the importance of these specialists they may be the reason that your doctor is able to make an accurate diagnosis of your problems. Veterinary medicine has long been a bastion for general practitioners. It used to be unusual for a veterinarian not to do surgery in addition to practicing medicine. Veterinarians willing to work with any species that walked through the door were the norm. Specialization in veterinary medicine was rare and most specialists were associated with veterinary teaching hospitals. Specialization pretty much meant doing research, some teaching and practicing in the specific field chosen. This situation is changing rapidly at this time.

It is not unusual now to have veterinarians whose practice is limited to cats, exotic pets or horses. Mixed animal veterinary practices (other than dog/cat or most farm animals) are not very common anymore, where they were once the standard. There are a number of reasons for this but perhaps the major one is that with all of the new information available it has become difficult to keep up with multiple species and to do a reasonably good job. This is especially true in the age of the Internet when it is possible for clients to seek information on veterinary care and to come to some conclusions about the level of care that is available.

At the present time our practice is almost entirely restricted to cats, dogs and small mammals such as guinea pigs and rabbits. In the past our practice started out as a mixed animal practice. We saw most of the species that people keep as pets or depend on for income. It became apparent that the economics of large animal practice and small animal practice were quite different. It is hard to equip and staff a small animal clinic and then leave it for half the day to drive around the countryside. In the office we have to generate several hundred dollars an hour in order to cover the overhead and make a profit. If I was driving to a farm 30 minutes away it was kind of hard to charge $200 for the call in order to cover those expenses. So when I was injured by a cow it was quite easy to make up my mind that the large animal portion of the practice had to go.

I used to do a lot of work with birds. There were a couple of aviaries in my county and they were quite busy. I purchased a fair amount of equipment that was mostly useful for working with parrots and other small pet birds. It was worth spending several hundred dollars a year on books and continuing education as well as keeping medications and lab equipment made for birds. In one year's time both aviary owners moved, leaving me with just a few pet birds in the practice. Over time it became obvious to me that I was losing my skills in diagnosing and handling the birds, especially since it no longer made sense to spend $500 to attend continuing education meetings dealing primarily with avian care. Now we send most of clients who have birds to a practitioner who maintains the equipment and skills necessary to help avian patients.

Just as a side note, I get a lot of ribbing from veterinary colleagues who practice in different situations when they hear me use the phrase "my county". The entire land area of county where I live and work is less than 100 square miles in size (water area is 166 square miles, though) and has a population of less than 10,000 people. It is a small place and we are the only vets in the county. I have friends who practice in cities who don't even think about what a county is and I have other friends who live in counties that have 20 or more veterinarians in them -- so it never occurs to them that there could be a vet who could say, "my county".

As we have made decisions over the years to restrict the scope of our practice those changes have mirrored general trends in veterinary medicine. Despite the limits in the species we would see, we still maintained a functioning hospital capable of providing most services to the pet species we continued to work with. Now further changes that are occurring in the availability of specialists are forcing us to rethink our place in the pet's health care again. It is now possible for our patients to have access to care ranging from MRI exams to kidney transplants, if we can locate the correct specialty facilities and refer to them. Except in very high income or very population dense areas, it is pretty hard for a general veterinary practice to purchase all of the necessary equipment for the majority of veterinary procedures available today and it is even harder to become highly skilled in the use of all of the equipment and laboratory procedures necessary to get good diagnostic information. When your pet has an ultrasound examination it is clearly best if the person performing the examination and interpreting the results does ultrasound examinations very frequently, for instance. With the increasing availability of surgical techniques and diagnostic equipment it is extremely difficult for anyone to become proficient in the use of everything that a need might arise for the course of a pet's life.

In addition to the availability of equipment there has been a huge expansion in the information pertaining to individual species, individual medical problems and general anatomy, physiology, pharmacology and pretty much every other "ology" in veterinary medicine. To apply information in practice it is necessary to have a pretty good working knowledge of the information. Just knowing that the information is available isn't enough to be able to apply it well during a 15 to 30 minute office visit. Some vets practice in situations in which it is possible to spend a half hour researching information that applies to a particular pet's problems but in many practices there really isn't enough time to do this on more than an occasional basis. In these types of practices it is extremely important that the general practitioner understand his or her limitations in this regard. Knowing what you don't know is at least as important as knowing a lot about any subject when it comes to making a good diagnostic and treatment plan. When a pet's illness falls outside the normal range of problems seen in a general practice it is very hard, but not impossible, for a general practice veterinarian to provide state of the art care.

Definitions

It is important to discuss some definitions at this time. According the veterinary practice acts in most states it is not legal for a veterinarian to call himself or herself a specialist in any field without being board certified in that field by a recognized certification organization. There are 20 recognized specialty boards in the United States at this time.

American Board of Veterinary Practitioners

American Board of Veterinary

American College of Laboratory Animal Medicine

American College of Poultry Veterinarians

American College of Theriogenologists

American College of Veterinary Anesthesiologists

American College of Veterinary Behaviorists

American College of Veterinary Clinical Pharmacology

American College of Veterinary Dermatology

American College of Veterinary Emergency and Clinical Care

American College of Veterinary Internal Medicine

Subspecialties in:

Cardiology

Large Animal Internal Medicine

Neurology

Oncology

Small Animal Internal Medicine

American College of Veterinary Microbiologists

American College of Veterinary Nutrition

American College of Ophthalmologists

American College of Veterinary Pathologists

American College of Veterinary Preventative Medicine

American College of Veterinary Radiology/Veterinary Specialty of Radiation Oncology

American College of Veterinary Surgeons

American College of Zoological Medicine

American Veterinary Dental College

Each organization has its own standards that aspiring specialists must meet. In veterinary medicine there has been an emphasis on academic and/or research in the specialty boards rather than an emphasis on clinical competence in the particular field. This seems to have occurred due to the fact that most of the specialty boards originated in college environments as a way to ensure that colleges were staffed with people whose interests matched the needs of the colleges. This orientation seemed to slow the spread of specialization in veterinary medicine and for some time there were few specialists in private practice. Eventually, the need for specialists and the opportunity to make more money than college salaries offered made private practice specialization more attractive. Now it is becoming hard for colleges to keep well qualified specialists and most veterinarian colleges have at least one or two specialties that are under represented. This has not changed the certification programs, though.

Of the specialties, the really relevant specialties for most pet owners are the dentists, dermatologists, surgeons, internal medicine specialists, ophthalmologists and behaviorists. For veterinarians seeking help with diagnostic information, radiologists, clinical pathologists, nutritionists, theriogenologists and anesthesiologists are important. Two of the specialty fields that are intriguing to me, as they are relatively new are the emergency vets and the board certified practitioners. These specialties are in fields in which the skill set overlaps markedly with general/family practice. Whether it will someday become important to folks that their family veterinarian is board certified or whether the emergency clinic veterinarian is board certified is going to be interesting to see. Right now, I suspect that most people aren't choosing their vets based on these certifications but there may come a time when they do.

There are many veterinarians who restrict their practice activities to certain areas such as dentistry or surgery who do not bother to get board certification because they have no interest in meeting the academic or research oriented requirements that still exist. These veterinarians may be much more skilled in certain procedures than someone who has board certification but they can not call themselves specialists in the Yellow Pages (tm) or on their practice signs or in their practice names. Sometimes the veterinarians in an area are pretty good about referring cases to a colleague who has a strong interest in a particular area of medicine or surgery. This type of referral seems to worry some veterinarians, though. There is a fear that the referral to a neighboring general practitioner might result in the loss of the client. Some clients don't seem to recognize that having a veterinarian willing to make appropriate referrals is probably more valuable than having a vet who is very skilled in one area, at least for general care of their pets. When vets are comfortable with this type of referral it is sometimes possible to get very good care near home instead of having to drive to a specialty practice.

The Relationship Between General Practice Vets and Specialists

Traditionally, the relationship between veterinarians and veterinary specialists has been very structured. Most veterinary specialists require referral from a general veterinary practitioner and won't see clients who try to schedule appointments themselves or who just walk in the door. In the last few years we have noticed that some of the specialists, particular dermatologists and ophthalmologists, are more likely to accept patients without a formal referral, though. I am not sure how this particular aspect of the relationship between veterinary specialists and general practitioners will evolve over time but my best guess is that it will become easier and easier to find specialists who will see patients without referral as time goes on. At the present time it is more likely that you will have to work with your vet to obtain a referral to a specialist that you wish to take your pet to.

The need for referral can be a major problem for some pet owners. There are veterinarians who really seem to believe that they can do everything that a pet would ever need. I have even spoken with a vet who told me something along the lines of "if I can't provide a service it isn't something a dog really needs, anyway." In this case, I was inquiring why a particular dog hadn't been referred for a total hip replacement but that attitude can occur with almost anything. I always hate to advise people to change vets but I really think that reluctance to refer to specialists is one circumstance that justifies changing vets, or at least having a back-up vet who is more willing to refer pets when there is a need to do so.

I am most worried about refusal to refer in situations in which a vet should be referring complicated surgeries or complex medical cases that just really require the help of someone who works with those types of cases very frequently. I refer most of my orthopedic procedures at this time, even though I have a fair amount of experience with orthopedic surgery simply because the board certified surgeon in my area is still more experienced and more likely to be doing almost any orthopedic surgery on a more regular basis than I am. Where he does two or three orthopedic surgeries per day, I was doing about 2 a month. It seemed to me that if I was going to have my knee operated on I would prefer to have it done by someone who was doing it every day rather than someone who had occasionally practiced the procedure. Why would I feel differently about my patient’s needs?

The relationship between specialists and general practitioners can be prickly at times. Communication between a veterinarian and client has a lot of potential to become complicated and adding a third veterinarian into the mix makes it that much more likely that communication problems might occur. There are two specialists in my area who seem to be competent in their specialties who I really have difficulty referring patients to because I just can't seem to communicate effectively with them. I want to know what happens to my patients so I expect the specialist to contact me and to let me know what the results of diagnostic procedures are or how procedures turned out. I am happiest when I get this information before the client comes back to the clinic for follow up visits. When this doesn't happen, especially when I have called to ask for the information, I am reluctant to refer to that specialist again. If the choice of specialists in an area is very limited this could become a major sticking point for a general practitioner. I am fortunate enough to practice in an area in which I have more than one choice for almost every specialist we need to refer to on a regular basis.

I have been irritated in some instances when I refer a patient to a specialist for a specific procedure and they take off in a whole different direction after their examination of the patient. I tend to want the specialist to at least consider the reason that I sent the patient to them in the first place, even if ultimately it becomes apparent that I am off track. I can work with this problem with the specialists who I can really talk to but it is much harder for me when the specialist gets angry that I am questioning their judgment or when the specialist seems to be assuming that I am just not well informed about medicine in general. It is particularly important to me in this situation that the specialist at least explain to the client why they think that a different course of action is necessary and why I might have thought otherwise.

To give you one example of how an interaction like this might occur, I sent a Jack Russell terrier to a specialist because I really thought that it had spinal disc disease causing lameness in the rear legs. Since I don't do myelograms and don't have access to an MRI machine it was necessary to refer this patient to a specialist who could provide these procedures. In the course of the initial examination she noticed that the dog was very sensitive to palpation of its feet. She took X-rays of the toes and discovered that he had arthritic changes. Her advice was to skip the diagnostic procedures for spinal problems and to work on the small joint arthritis first. As it turns out this was very good advice since the patient got better. However, my client had some questions about why I didn't discover this problem and it was a little embarrassing -- but the specialist had at least told them that this was a problem she was noticing in more and more Jack Russell terriers and not widely recognized in the literature, yet. That little bit of information was very helpful in our relationship with both the specialist and the pet owner. A specialist who didn't make an effort to explain why their conclusions are much different than the referring practitioner might undermine the relationship that a veterinary practice has with the client. If this happened more than once or twice it would almost certainly cause the general practitioner to think hard before referring to the specialist.

Over the years there have been two specialists who I simply had to stop referring patients to. In one instance the specialist simply seemed to loose touch with reality over time. He had been an extraordinarily good internal medicine specialist for much of his career but for the last few years he developed some odd theories about why particular problems were occurring and we couldn't refer to him with confidence that the patient would receive adequate care. In the other case, we have a specialist in our area who is simply obnoxious. He has cursed at two of our clients. The only reason it happened twice is that we weren't sure the first client hadn't started the controversy as he had been somewhat difficult at our practice at times. This is something that really doesn't have much to do with this specialist's skills but we can't refer our clients to a practitioner who might insult them or treat them badly as that reflects badly on our choice in sending them there.

In addition to the specialists we simply won’t refer to we have some specialists who we are very careful about making referrals to. We will refer some cases but not others, based on several criteria. Sometimes a specialist is very good in one aspect of their specialty but not very good at the problem that a particular patient has. In other cases we know that a specialist doesn’t refer the patient back to us for the follow up care and we feel that the patient has overall needs that might not be met. In a few rare instances we have really strong disagreements with area specialists over particular aspects of care and we feel that a particular patient is better off going to a specialist who agrees with our view of care more closely.

There are instances in which we simply can’t refer to the specialist we would prefer. We have some clients who simply must be referred to the closest person who can provide the services the pet needs whether they are the best choice, or not. Some pets must be referred to facilities that can provide 24 hour care for several days after surgery or treatment. It is not highly unusual for us to have to send a patient to whichever specialist can take them on an emergency basis. We try hard to match the patient with the most appropriate specialist, but these types of considerations can have a big impact on the decision making when it comes to choosing a specialist.

Specialists can sometimes be difficult about care required before referral or during follow-up after referral. It shouldn’t be necessary for a client to drive 200 miles to go back to a specialist for suture removal or to have blood drawn for testing that can be done through the patient’s usual veterinarian. Specialists who insist that all care take place at their facilities can place an undue burden on pet owners and sometimes this becomes a factor in the decision over who to refer a case to. It seems better to me to refer to a specialist who trusts us enough to allow us to handle the portions of the pet’s care that are fairly routine. This saves the client money and time in most cases without endangering the pet’s care. Of course there are times when it really is a good idea for the specialist to see a pet for follow up care and the general practitioner and pet owner have to cooperate for the pet’s best interest, as well.

When Referral is Important

There are a number of different scenarios that can arise that may or may not require referral from a general practitioner to a specialist. I will try to outline some of these so that you can see my thinking and decide how that might apply to situations where you feel your pets might benefit from referral to a specialist.

I can remember working with my dad on several home improvement projects. One of the pieces of advice he almost always gave during the course of these projects was, "Having the right tool is 50% of the job." Sometimes that percentage would vary. It might be 70% of one job or 90% of another but it was almost always at least 50%. My dad liked tools and had a big collection of them, so perhaps he was a little biased in this regard. It is possible that there are jobs where having the right tool is less than 50% of the difficulty of a task. In any case, I think that my dad was adjusting the percentage of importance of having the correct tool to the task at hand. Over the time I have been in practice it has become clear to me that there are some things that just can't be done without having the exact tool necessary to complete the task. Having access to the right tool is one of the major reasons that veterinarians refer a patient to a specialist. In some cases, there simply is no choice in who to refer a case to. I have to send the patient to the specialist who has the tool or facility to provide the service.

In a small number of cases this limits the referral choices to one or two people or facilities in the entire country. There are very few places in the country where it is possible to have a kidney transplant done if a dog seems like it might benefit from it, for instance. As far as I know, only Auburn University has an active program for hypophysectomy surgery for patients with pituitary dependent Cushing's disease. Lithotripsy is available for dogs with urinary tract stones but it is not widely available. Colorado State University developed surgeries for saving the limbs of pets with osteosarcoma rather than relying solely on amputation. There are a number of other examples of procedures that might require traveling to a specific specialist from wherever you might be. I have had clients who have taken pets from Virginia to New York, Colorado, Arizona, Florida and in one case even to the Netherlands in order to have specialized care that was only offered in those places. It may be necessary to convince your vet that you are willing to see a specialist anywhere in the country but if you are, make sure that your vet really understands that.

In some cases there is no need for specialized equipment but there is still a strong need for specialized expertise. This may actually make the choice of who to send a pet to much harder as it can be difficult to determine who is the real expert in a particular problem. As you might have noticed from the list of specialties, there can be some broad overlap in the types of services provided by a particular "specialist". To give you one example of this, the person I trusted most to do the cardiac ultrasound examination of Henry was not a board certified cardiologist. I chose an internal medicine specialist who emphasizes cardiology but has never actually been certified in the subspecialty of cardiology. In my area it was the choice I was most comfortable with. In most cases it is best to refer to a specialist who is board certified in the area of care that your pet needs. However, if your vet suggests referral to a particular person and it doesn't seem to jive with what you think is necessary ask what your vet's reasoning is. You might find that there is a very good reason for the referral.

We have encountered situations in which we made a referral to one specialist and the pet was then referred to another specialist. This isn’t common but when it happens it is a good idea to take the advice and go see the third person. Specialists often know who is best at a particular problem in their field much better than a general practitioner does.

We have also encountered situations in which we referred a patient to a specialist and then strongly disagreed with the specialists diagnosis or treatment choice. When this happens we try to have a frank discussion with the client about the situation. Sometimes this doesn’t work very well. I can remember a client asking me, “Why did you send me there is you didn’t trust the specialist?”. Fortunately, in that case I deeply trusted the specialist and was able to convey that, I just disagreed with her diagnosis.

For most clients I think that a situation in which their general practitioner saw a need to make a referral to a specialist and then disagreed with the specialists findings would be very disconcerting. This has happened to us enough times that I know that clients can be quite upset when it happens. I also know that they can make bad choices based either on trusting me too much or trusting me too little in this circumstance.

It can be very hard, but when your vet disagrees with the specialist, or when two specialists are involved in the case and they disagree, you are going to have to decide whose recommended course of action to take. If you have a strong gut feeling or if you feel that you know enough about a subject to make an informed decision then you should probably just make a decision. If you are really confused it is perfectly acceptable to get a third opinion, fourth opinion or even fifth opinion about the case. Of course, at some point you still end up having to decide what to do but it is generally reasonable to go with the majority opinion if there are three or more vets involved.

To give you an extreme example of this, we sent a pathology sample to the lab we use most frequently. It was a skin biopsy from a suspicious looking area. The first pathologist to read the sample thought that it was cutaneous lymphoma. Since this is a particularly bad tumor to deal with I asked for a second opinion from a dermatohistopathologist. This pathologist thought that the lesion was just reactive tissue but wasn’t sure and sent the sample to another pathologist. This pathologist was heading off to a meeting of pathologists. We ended up getting five opinions, two for cutaneous lymphoma, two for reactive tissue and one that said the sample wasn’t conclusive for anything. While the debate was going on the lesion disappeared and out patient has been fine since so we think that the pathologists going for reactive tissue were right but it was hard on the dog’s owner while all the decision making was going on.

Sad facts about Specialists

Sometimes just going through the procedure to become a specialist doesn't make a veterinarian a good animal doctor. In fact, in some cases I think that specialty training actually makes it harder for a veterinarian to have a good practical background. A veterinarian who goes directly from veterinary school into an internship in their chosen field might never gain a really good understanding of general practice and can even be very limited in their ability to think of a pet as a whole being instead of a life support system for a heart, or a life support system for a kidney, or whatever other body part they have the strongest interest in. My pet peeve is a veterinarian who goes directly from veterinary school into emergency medicine and doesn’t take a year or two to see what general practice is like. Without this exposure it is very easy to overlook the long term outcome of a procedure in favor of short term results. Never getting to see the consequences of your decisions over the longer term makes for bad decision making in some emergency care veterinarians.

Specialty training can’t make up for a lack of empathy. Veterinarians who let their emotions override their training still make it through the internships, residency training and additional classroom time that specialty practice requires. Problems like alcoholism and drug dependency can rob specialists of their skills just like they can rob general practice vets of them. Hopefully your veterinarian will help you avoid specialists who

Specialists sometimes forget to take into account how their decisions for treatment of one organ system impact the overall care of a pet. This is one area in which general practitioners really do make a big difference. By keeping the overall needs of the patient in mind it is possible for a general practitioner to notice conflicts with medications or therapies that a specialist might not think about.

Specialists are usually more expensive to visit than general veterinary practitioners. Aside from the extra years of education there are good reasons for the difference in price. Most specialists try to have up-to-date equipment and to participate heavily in continuing education. In addition they often schedule longer office visits than general veterinary practitioners. Since specialists see patients who usually have more difficult problem than the average pet they have to schedule more time for office visits than most general practitioners. Finally, the specialist has a reputation to keep up both with the referring vets and the clients who bring patients to them. They can’t really cut corners or take a “wait and see” approach very often without risking their relationships with referring veterinarians and pet owners with high expectations for success.

Even at the best referral facilities a conclusive diagnosis can be hard to come by. There will always be disagreements over diagnoses, treatment options and prognoses for some patients. While I think it would be great for my patients if medicine wasn’t such a complex subject it wouldn’t be nearly as interesting a field to work in if this wasn’t the case. I try to accept the unknowns to the best of my ability and to help my clients do that when it is necessary but proper use of specialists and experts can reduce the uncertainties to some degree. Right now, this is the best that we can do.

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The opinions expressed in this newsletter are those of Michael Richards, DVM., author.