VetInfo Digest December 1999
This Month:
Are There Veterinary Specialists?
What is a Specialist and Why Aren’t There More of Them?
Boards and Colleges that Certify Specialists
Why is a Referral Required?
When Do I Need an Ordinary "Second Opinion" and When Do I Need a Specialist?
Money Concerns and Specialists
This month, we are going to have to make use of both the newsletter format and the ability to put information on our subscriber website that simply won’t fit in the newsletter. There are several veterinary specialty boards whose addresses will only be interesting to a few people. These addresses will be in the subscriber area rather than the newsletter. If this works well, we may try to use the subscriber area for photographs or other illustration materials that we can’t reproduce in the newsletter.
We had a problem with email this month when our local ISP made equipment upgrades which caused problems with our accounts. If there is ever a situation in which you can not reach me at mervet@inna.net, Michal will forward mail to me from our vetinfo@vetinfo.com email address.
Veterinary Specialists
In the last few months several people have asked me if specialists existed in veterinary medicine or if it was a good idea to consider going to one. There are specialists available for pets with difficult health problems and it is often a good idea to consider seeing one.
What IS a Specialist and Why Aren’t There More of Them?
The definition of a "specialist" may be slightly different in veterinary medicine than you might expect. In most states it is not legal for a veterinarian to claim to be a specialist without being recognized as such by one of the existing specialty boards affiliated with the American Veterinary Medical Association. Certified members of a specialty board are usually referred to as "Diplomates" of the board and will have an additional set of letters signifying this after their signature, such as John Doe, DVM, ACVIM or John Doe, DVM, Diplomate, ACVIM. In this case, ACVIM stands for American College of Veterinary Internal Medicine. There are subcategories of specialists recognized by some boards. The ACVIM recognizes specialties in cardiology, internal medicine and oncology, for instance.
Specialization in veterinary medicine did not originate from a demand by the public for specialists with advanced training in their fields or whose capabilities are measured by testing or practical experience. It came about because academic veterinarians felt a need to distinguish themselves from ordinary veterinarians for career purposes and certain industry veterinarians had the same needs. These groups had a desire to prove that they were more fit for their jobs than general practitioners.
In response to this "colleges" and/or "boards" representing some of the specialties were created and members had to meet certain academic and testing criteria in order to become diplomates of the organization. Because these boards were created by academic veterinarians, for academic veterinarians, they lean heavily towards requiring formal internships and residencies. Most of the boards require prospective members to have writings published in a refereed journal (one reviewed by other specialists in their field) or to meet other writing requirements.
I would not consider this situation to be unfortunate if there were not a demand by the pet owning public and from veterinarians in general practice for qualified specialists in many fields. At the current levels of debt and prospective income for veterinarians it seems unlikely to me that the demand for specialists will be met anytime soon. Most veterinary students can not afford to stay at school for an internship or residency. Those that do often spend no time at all in "real" clinical practice, spending their careers at veterinary schools or in industry positions. Incredibly, interns, and sometimes even residents, in some veterinary specialty programs are not paid or may even have to pay for their internship programs. These are graduate veterinarians who usually are seeing patients and providing income for the institutions they work for. This is a huge impediment to meeting the demand for specialists in veterinary medicine.
On the other hand, specialists are finding it harder to stay on an academic track. There are only twenty-seven colleges of veterinary medicine in the United States and only four in Canada. Faculty positions may not open up for years once they are filled. So despite the heavy emphasis on academics that the current system is biased towards, many specialists are finding their way into private practice at the present time. This is good news for pet owners because it means that it is more likely that your pet can see someone with specialty training close to home -- especially for the states in which there is no veterinary school to refer patients to.
The American Board of Veterinary Practitioners was formed several years ago to try to recognize veterinarians with excellent skills in clinical practice. This board does not require internships or residencies, but has a requirement that diplomates have six years of clinical practice prior to becoming eligible for the board. In addition, this board does recognize species specialization, such as feline specialist, which is important to many pet owners. This board hasn’t taken off quite as well as it might have, possibly due to the fact that most veterinarians in small animal practice see both dogs and cats -- making a "specialty" in dog and cat practice somewhat of a moot issue. At present, diplomate status in this board shows that a veterinarian has continued to learn after completing veterinary school and shows strong dedication to veterinary practice.
I hope to see some modifications in the specialty requirements in veterinary medicine over the next decade. I would like to see specialization requirements become less academically and more clinically oriented. This will allow increased availability of specialists in fields in which they are sorely needed and still ensure pet owners that the person they take their pet to does have advanced skills in areas such as dermatology, surgery or dentistry. In all honesty, I don’t think that this is going to happen quickly. The specialists who control the current boards, and who went through the whole process to get there, do not see much need to change the system in a way that lessens their perceived status. For the time being, it is likely that specialization will continue to be an academic adventure. Clinical experience in specialized subjects is not likely to be accepted as an acceptable alternative to formal education for some time.
A Review of the Specialty Boards
There are twenty specialty boards in veterinary medicine at the present time. They can be roughly categorized into several categories. Most of these categories are of little interest to pet owners, but I thought it was worthwhile to list them, anyway. I have included contact information for organizations that it seems likely readers might want to have. I will post the contact information for the other organizations in the subscriber area, just in case someone has an interest.
Boards With Strong Industry or Academic Affiliation:
American College of Laboratory Animal Medicine (~600 Diplomates). Veterinarians who supervise and manage lab animal health or research programs, usually at veterinary or medical schools or in industry positions.
American College of Poultry Veterinarians (250 Diplomates) This one is self explanatory, except that I would be surprised if any of these specialists were in private practice. This is an industry driven specialty.
American Board of Veterinary Toxicology (93 Diplomates) This specialty also is primarily an academic and industry driven specialty. It is not likely that a huge demand for veterinary toxocologists in private practice will develop.
American College of Veterinary Clinical Pharmacology (25 Diplomates) Veterinarians have traditionally served as pharmacists (or at least dispensers of medicine) in their practices. Veterinary schools tend to have a pharmacology specialist, although there are fewer diplomates in this field than there are veterinary schools. The use of the word "clinical" to describe this group always strikes me as suspect. They may study the use of pharmacology agents as they might be used in clinical settings but I don’t think many of these diplomates have jobs that resemble clinical practice very much.
American College of Veterinary Microbiologists (279 Diplomates) If any of the members of this specialty board are in private practice in their field, I am unaware of it.
American College of Veterinary Pathologists (~1170 Diplomates) Many veterinarians in private practice do send clinical specimens to veterinary pathologists. It is important, whenever possible, that veterinary tissue samples be reviewed by veterinary pathologists, because there are sometimes subtle, and occasionally blatant, differences in the way in which veterinary pathologists and human pathologists describe tissue samples. Many diplomates of this board work in health care industries, such as pharmaceutical firms.
When your vet sends a biopsy or tissue sample from your pet to a referral lab it is fair to ask if the lab has board certified veterinary pathologists on its staff and if they review the slides of veterinary cases.
American College of Preventative Medicine ( 600 Diplomates) This board also recognizes a sub-specialty in epidemiology. Diplomates of this specialty tend to work for the government or at veterinary or medical schools but there are industry positions, as well. Veterinarians are well qualified to help with preventative medicine measures for humans, especially those related to zoonotic diseases.
American College of Veterinary Nutrition (48 Diplomates) There may come a day when small animal veterinary clients and their pets are referred directly to veterinary nutritional specialists for consultation on dietary measures that might improve pet health. Right now, that doesn’t happen very often. At the present time most of the veterinary nutritionists primarily involve themselves in production medicine, making sure that animals raised for food are fed diets that are optimized for specific goals such as rapid growth or disease resistance. There are a few small animal nutritionists available, though.
American College of Veterinary Radiology (187 Diplomates) Subspecialty of Radiation Oncology (29 Diplomates) Veterinary radiologists are an underutilized resource by most veterinary general practitioners. It is difficult to read X-rays consistently well in clinical settings and many pets would benefit from review of their radiographs by a veterinary radiologist. We try to send any X-rays we do not feel certain about to a veterinary radiologist for review. We use a veterinary college’s services but there are private "tele-medicine" companies which offer review of radiographs and consultation about the findings. If your vet takes skull, chest or abdominal X-rays of your pet it is worthwhile to ask that they be reviewed by a board certified radiologist. Most of the time the radiologist isn’t going to change the diagnosis or interpretation made by the general practitioner but when they do see something different it can help to save the pet’s life.
American College of Zoological Medicine (47 Diplomates) Most, or perhaps even all, of the diplomates of this organization work at zoological parks around the country.
Specialists Your Vet Might Actually Want to Send You and Your Pet To:
The list of specialties that your vet might actually want to send you and your pet to is smaller. These specialists are usually practicing some form of clinical medicine and they often have information on new medications, new treatments and changes in research findings sooner than general practitioners. They tend to see the most difficult cases in their specialty and they see enough patients in specific fields to recognize rare disorders more readily than a general practitioner might.
American Board of Veterinary Practitioners (ABVP) (336 diplomates). Contact: Dee Ann Walker, Administrator, 530 Curch Street, Suite 700, Nashville, TN 37219-2394
Phone: 615-254-3687 www.abvp.com Certifies Diplomates in: Avian Practice, Beef Cattle Practice, Canine and Feline Practice, Dairy Practice, Equine Practice, Feline Practice (43 diplomates), Food Animal Practice and Swine Health Management
It is actually not that likely that your vet will refer you to a ABVP specialist, since most are in general practice themselves. However, if you are seeking a second opinion on your own and you wish to find someone who is likely to be practicing at a level equal to or above the level of your general practitioner, it would be worthwhile to look for ABVP certification. It would not surprise me if there were referrals to feline specialists from this board due to the difficulty in treating some diseases in cats.
American College of Theriogenologists (300 Diplomates), Contact: Don Elleree, Executive Director
P.O. Box 2118, Hastings, NE 68902-2118. Phone 402-463-0392
Theriogenologists are specialists in reproduction. This board does not certify diplomates by species. Due to the economics of veterinary medicine most of the diplomates of this board probably have an interest in reproduction from a food animal perspective but there are some specialists with an interest in dogs and cats. If your pet has a reproductive problem or you need help with health care issues involving reproduction, these are the people to see. There are a limited number of theriogenologists in private practice and veterinary colleges have theriogenologists, as well.
American College of Veterinary Anesthesiologists (126 Diplomates) Contact: Dr. Richard Broadstone, Executive Secretary, Department of Small Animal Clinical Sciences, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Tech, Phase II Building, Duckpond Drive, Blacksburg, VA 24061-0442 Phone: 540-231-9268 email: broadstr@vt.edu
In general practice, and even in surgical specialty practices, there usually will not be a board certified anesthesiologist. However, for patients in which a great deal of difficulty with anesthesia seems likely, there are anesthesiologists available for consultation at veterinary schools and some of the larger referral centers. If your pet needs surgery in which anesthesia is a major concern the presence of a board certified anesthesiologist during the surgery would be a major factor in choosing where to go for surgery. Your vet may not think about this aspect of a surgical procedure, so if you have concerns it would be a good idea to ask specifically whether a board certified anesthesiologist will handle the anesthesia when your pet has surgery.
American College of Veterinary Behaviorists (18 Diplomates), contact: Dr. Bonnie Beaver, Executive Director, Department of Small Animal Medicine and Surgery, Texas A&M University, College Station, TX 77843-4474 phone: 409-845-2351 email: bbeaver@cvm.tamu.edu
While there is a desperate need for specialists in this area it is unlikely that there will be a big increase in behavior specialists anytime soon. Training options are limited due to the limited number of diplomates at this time and there is still a reluctance among pet owners and veterinarians to consider consultation with a behaviorist. If you are lucky enough to live near one of these specialists they can help a great deal with most of the behavioral problems that affect pets and their owners. The initial consultation fee may seem a little high but over the long term good behavioral advice can save both money and pet’s lives. Don’t hesitate to ask your vet about referral to a specialist. Don’t hesitate to go a long way for this help if you and your pet need it. Fortunately, much of the follow-up work in behavioral cases can be done by telephone or e-mail and it is usually not necessary to make repeated long trips to the behaviorist at frequent intervals.
American College of Veterinary Dermatology (113 Diplomates), contact: Ms. Alexis Borich, Executive Secretary, 5610 Kearny Mesa Road, Suite B, San Diego, CA 92111 phone: 619-560-9393
Dermatologists are making definite inroads into private practice. There are veterinary dermatologists practicing in many cities now. Since veterinary schools usually have dermatologists, as well, it is possible for most people to find a dermatologist within a few hundred miles of their home. This is a good thing because many skin diseases must be managed, rather than cured, and correct identification of the problem obviously makes management a much easier and more reliable process. In addition, most dermatologists also serve as allergists, doing skin testing for allergies and helping to manage allergic patients. We refer a number of cases to dermatologists in our area and this has helped several of our patients who I was not having good success treating. If your pet has persistent skin disease it is worthwhile to ask your vet about referral to a veterinary dermatologist.
American College of Veterinary Emergency and Critical Care (ACVECC) (64 Diplomates), contact:
Dr. James N. Ross, Executive Secretary, Department of Clinical Sciences, School of Veterinary Medicine
Tufts University, 200 Westboro Road, North Grafton, MA 01536 Phone: 508-839-7950 email: jross@infonet.tufts.edu
At the present time it is not unusual at all for veterinarians to refer emergencies to an emergency clinic (EVC) at night or over weekends. Most EVCs do not have a board certified specialist but it is reassuring when they do. This practice is here to stay, I think. There isn’t a good legal defense to explain operating on a pet, all alone, when an EVC is available. Trying to run an anesthetic machine, monitor the patient, do surgery and provide reassurance to the client all at the same time really isn’t possible, so when veterinarians provide their own emergency coverage they are making some compromises in one of these areas. If you don’t want your pet’s emergency care to involve compromise, seek out a good emergency clinic. Checking for Diplomate status in the ACVECC is a good step in evaluating your local emergency veterinary clinicians.
American College of Veterinary Internal Medicine (ACVIM), contact: Ms. June Pooley, Executive Director, American College of Veterinary Internal Medicine, 2750 S. Wadsworth, Suite C-109, Denver, CO 80227-3400 Phone: 800-245-9081 email: acvim@aol.com
Subspecialties recognized: Cardiology (92 diplomates), Internal Medicine (about 800 diplomates), Neurology (94 diplomates), Oncology (90 Diplomates)
The ACVIM comprises a mixture of private practitioners, veterinary faculty members and industry personnel. This is one of the older specialty boards. Its requirements for internships and residencies and publication makes it more academically inclined than the newer American Board of Veterinary Practitioners. This is the group of specialists that your vet is probably most likely to refer you to. Advanced diagnostic testing and a greater familiarity with difficult cases and unusual disorders makes a Diplomate of the ACVIM a good choice when a veterinarian feels that a second opinion is necessary or that advanced care beyond the capabilities of the practice must be found. Due to the large number of diplomates of this board there is a very good chance that there is an internal medicine specialist within easy driving distance of your home.
American College of Veterinary Ophthalmologists (ACVO) (308 Diplomates), contact: Dr. Mary Belle Glaze, Secretary/Treasurer, Veterinary Clinical Sciences, Louisiana State University, Baton Rouge, LA 70803, phone: 504-346-3333 email: mglaze3937@aol.com
Most pet breeders are familiar with the ACVO, due to certification programs for breeding pets such as CERF. Ophthalmology requires very specialized equipment beyond the basic levels and veterinarians may be quicker to refer ophthalmology cases than most other problems. Many ophthalmologic problems are emergencies, so if your vet suggests referral to an ophthalmologist make sure that you understand the amount of time you have to get there without compromising your pet’s vision or health. Fortunately, many veterinary ophthalmologists are in private practice now and it is generally possible to find an ophthalmologist quickly when necessary.
American College of Veterinary Surgeons (ACVS) (780 Diplomates), contact: Ann T. Loew, EdM, Executive Director, 4401 East West Highway, Ste. 205, Bethesda, MD 20814-4523 Phone: 301-913-9550, email: acvs@aol.com, URL: www.acvs.org
It is usually possible to find a board certified veterinary surgeon with a few hundred miles of most places in the U.S. This is a good option for difficult surgeries. For surgeries that require significant aftercare it is often better to consider going to one of the veterinary schools, simply because they have the ability to provide around the clock care due to the number of students (free labor) and staff members. Your vet will almost certainly have a surgeon that he or she sends patients to for really difficult procedures. The level of difficulty a practice takes on prior to referring a surgery varies widely. It is a good idea to ask your vet whether it would be better to have a surgical specialist perform difficult surgeries, if you are willing to make the trip and pay the additional cost, since most surgical specialists charge more than general practices.
American Veterinary Dental College (AVDC) (47 Diplomates), contact: Dr. Frank Verstraete, Secretary
American Veterinary Dental College, Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, CA 95616-8745 Phone: 530-754-8245 email: fjverstraete@ucdavis.edu
Veterinary dentists provide most of the same services as human dentists, although there is not much call for false teeth in veterinary medicine. Tooth repair is possible for damaged teeth, ordodontia is frequently performed and periodontal treatment is common, as well. Veterinary dentists are the specialist that your vet might not think about referring you to. Many vets assume that pet owners would rather pay for an extraction than repair a broken tooth or that orthodontic care for a pet would seem silly to a pet owner. You may have to ask specific questions in order to prompt your vet to refer you to a veterinary dentist, such as "is there any way this tooth can be saved?", or "if that tooth is going to cause problems, will braces correct the problem?" Due to the widespread problem with periodontal disease in pets there are many teeth that it really isn’t possible to save, but broken teeth can often be repaired rather than extracted and even some very difficult cases of periodontal disease can be reversed with aggressive care.
Why is a Referral Required if I Want to See the Specialist?
Most veterinary specialists will only see new clients and new patients on a referral basis, with the notable exceptions of members of the American Board of Veterinary Practitioners and emergency specialists, who are usually in general practice themselves.
Veterinary specialists rely on surrounding general practitioners to send difficult cases to them. Specialists are usually dependent on the referring practitioner for medical history and for follow-up care. Their practices are limited to their specialty, so they usually can’t provide services such as vaccinations or routine health care. In order to maintain a good working relationship with the practitioners who supply their business and to best serve the patients who come to them, the system of accepting only patients specifically referred by veterinarians has developed. Not all specialists practice this way but when they do, they are usually absolutely insistent on having a referral.
This situation presents problems when a general practitioner won’t refer a patient to a specialist. In some cases it is necessary to find another general practitioner who will make the referral. This isn’t often a problem but I know that it does occur. If your vet refuses to refer you to a specific specialist you should ask why. Your vet may have sound reasons for avoiding a particular referral but not be against referral in general. There are specialists who I am very reluctant to refer patients to. A specialist in your area may be difficult to work with and clients may have complained about the way they were treated at the referral practice. A specialist may have unusual theories about some disease mechanisms that make your vet hesitant to make referrals for these diseases. I am reluctant to explain these situations in my practice unless a client is insistent on seeing a particular specialist I have had problems with.
When your pet is struggling with a health problem and your vet is having difficulty making progress in treatment it is reasonable to ask for referral to an specialist. Don’t hesitate to do this. Sometimes just asking is enough to let your vet know that you are serious about making your dog or cat well and may prompt your vet to go ahead and perform more costly tests or explore other options that he or she may have been avoiding. In other cases, the specialist is a necessity and you r vet will recognize the need.
When Do I Need a Specialist Instead of an Ordinary "Second Opinion"?
This question is really difficult for me to answer. Sometimes just seeing a different veterinarian does make a significant difference in a case. Another veterinarian may have seen a case similar to your pet that makes it possible to get to a diagnosis your own vet was struggling with. Neighboring practices often have significant differences in interests and equipment. This makes it seem very reasonable to seek a second opinion locally before going to a specialist.
On the other hand, just about every area has a veterinarian who isn’t keeping up anymore. Strangely, these are often very popular veterinarians whose bedside manner is masking deficiencies in practice skill. It may take several visits before it becomes apparent that the great first impression is giving way to suspicion. Ask your vet who it would be best to get a second opinion from locally if you have to -- or ask if there are one or two vets that shouldn’t be included in a search for a second opinion.
If your pet is critically ill, if your pet has already seen more than one local practitioner without successful resolution of a problem, if you have allowed appropriate testing and followed treatment directions carefully, without success, and if you value your future relationship with your vet, ask about referral to a specialist.
Money Concerns and Specialists
The last issue with specialists is cost. It is almost always more expensive to seek help from a specialist than from a general practitioner. The cost is justified by the additional expenses the specialist incurred in education and in equipment. Their skill level is often higher than a general practitioners.
Your veterinarian can’t provide an accurate quote for someone else’s services but may be able to give you a ballpark figure of potential charges for specialty services. If you are determined to get the best care, then cost may be a secondary concern. However, if you know that you have limited resources, you may have to refuse a visit to a specialist and work out an alternative plan with your own vet. If this happens it is possible that your vet may ask you to sign a release stating that you refused referral to a specialist before he or she will be willing to proceed with difficult diagnostic testing or surgery. That isn’t a bad thing, as it makes it clear to everyone that your vet is doing his or her best in a difficult situation.
It is often less expensive over the long run to use a specialist’s services. Getting an accurate diagnosis of a chronic skin disease or having an orthopedic surgery done that prevents long term treatment with pain-relievers may actually save money in as short a time as a few weeks to a year. If your vet recommends referral to a specialist consider the option carefully. If your vet never mentions the availability of specialists but your pet has a condition that seems to warrant a specialist’s care, ask if a referral to a specialist is appropriate. If your vet refuses to refer you to a specialist get a specific reason for the refusal or seriously consider changing veterinarians. Veterinary medicine has become complicated enough that the use of specialists is becoming a necessity for many procedures.
As we enter a new millennium and look forward to advances in veterinary medicine that will make life better for pets and for their owners, we hope that one of those advances is the service we provide through this newsletter and our website, www.vetinfo.com
You have helped make this service possible through your subscriptions. We thank you for helping us in our mission to provide a source of information on scientifcally based veterinary medicine that is as accurate as we can make it. We hope to continue to provide this service for as long as people like yourselves see the need. We simply couldn’t do it without you!
The VetInfo Digest is published by TierCom, Inc., P.O. Box 476, Cobbs Creek, VA 23035. The opinions expressed in this newsletter are those of Michael Richards, DVM., author.
Copyright Tiercom, Inc. 1999
This page was last edited 06/21/04
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