Entering a new era

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Many believe the growth of specialty practices benefits the entire profession.

NATIONAL REPORT — Veterinary professionals have suspected for years that the number of board-certified specialists has been rising. Now the numbers prove it.

Raising the bar: "One of the hardest aspects of my job is realizing that the diseases are sometimes stronger than we are. There are many times that we lose the battle, but there are also many times that we take a very sick dog or cat and are able to provide them with a fantastic quality of life," says Anne Dalby, DVM, Diplomate ACVIM internal medicine specialist with Veterinary Referral Clinic & Emergency Center, Bedford, Oh.

According to the American Veterinary Medical Association (AVMA), there were 8,510 active, board-certified diplomates as of Dec. 1, 2006. This is already a substantial increase from 6,983 in 2001, and more are on the way: 514 new candidates are ready to take the certification examinations this year from the 20 AVMA-recognized veterinary specialty organizations — about 100 more than there were just three years ago.

Dr. John Albers, executive director of the American Animal Hospital Association (AAHA), says this growth extends across all specialties and is having a major impact on the veterinary profession. "Specialty medicine has represented a huge change in the delivery of care to companion animals," Albers says. "You can now find multiple specialists in every metropolitan area of the country."

Most experts agree that clients are the primary force driving this trend. The intensely emotional human-animal bond is creating increased demand, and willingness to pay, for advanced medical care and the latest technology for diagnostics and treatment – services that only a specialist can provide. "Expectations are higher," Albers says. "People are more willing to be referred to a specialist if the case is unusual or serious."

Motivating factors

Swayed by ambition, fascination with a particular field, the opportunity to administer an advanced level of care and a significantly higher salary, more veterinarians are seeking advanced certification to meet pet-owners' demands.

The American College of Veterinary Internal Medicine (ACVIM) had 403 candidates in residency training programs this year. There were 332 candidates in 2002, the year Dr. Alan Spier, DVM, PhD, received board certification from ACVIM in cardiology.

"A lot of people might go into veterinary medicine because it allows you be the jack-of-all-trades," says Spier, who works at Florida Veterinary Specialists in Tampa. "I'm OK not being a good surgeon. I'm OK needing to defer to other people, but I wanted in one small area to do a really good job."

There's also significant financial incentive to become a specialist, which can trump the time and expense advanced education requires. To achieve board certification with the ACVIM, a DVM must complete a three- to five-year internship and residency in his or her specialized field, then pass at least two years of rigorous examinations. After this extensive training, the private practitioner can hope to earn a median salary of $134,500, compared with the median DVM private practitioner's $77,500, according to the AVMA.

The result of this trend has been a widely acknowledged advancement in veterinary medicine. "The level of care is increasing across the board in general practice as well as specialty practice," says Dick Goebel, a consultant at Simmons & Associates veterinary practice brokers.

Impact on academia

Ten years ago, the most common career path for a specialist was to become a teacher or researcher in academia, but the latest wave of specialists is heading more toward lucrative work in the private sector.

Multiple choice: Dr. Anthony J. DeCarlo, VMD, is co-owner of Red Bank Veterinary Hospital in Tinton Falls, N.J.,which bills itself as the nation's largest privately owned veterinary hospital that offers primary and specialty care.

There are 2,987 active, board-certified specialists primarily associated with academia and 3,196 with private practice, according to the AVMA. In 2006, 802 ACVIM diplomates were in private practice and only 662 were in academia. The gap was smaller just three years ago, when there were 50 more diplomates in private practice than in academia. This has left veterinary colleges struggling to find enough teachers and researchers.

"There's a very obvious path from certification to private practice now," says Dr. Joan Hendricks, the Gilbert S. Kahn dean of the University of Pennsylvania's School of Veterinary Medicine. "What we have to offer is teaching the next generations, but we can't really match the salaries."

Financial return is once again a primary motivator for this trend. Recently certified specialists who have just finished their residencies often are burdened with a large financial debt, and are looking to recoup their losses as quickly as possible.

The median salary of a specialist in academia is $103,000, compared with the $134,500 made by a private practitioner. Goebel does note that this figure is offset by an academic benefit package that's about double the size of the benefit package in the private sector.

Spier was head of cardiology for three years at the University of Missouri before leaving in 2005 for private practice. He says there are many advantages to working in academia, including the opportunity to give back to the profession, a more flexible schedule and better vacation time. "I was actually reluctant to leave academia," he says. "The only thing that allowed me to do it was finding a practice that had an academic feel."

Actually, the growing number of specialty practices creates interesting options for training that could enrich the curriculum at veterinary colleges.

Hendricks, VMD, PhD, is particularly focused on providing students with research experience. Although it's appropriate that specialists are trained with an eye toward patient care, she says it becomes a problem when they are expected to do research upon entering academia. "We are trying to capture people who are in the middle or end of their residency training and are seeing that they'd like to make a difference and do research," Hendricks says.

One of the major factors driving specialists away from academia, Spier says, is that they must do research, teach and work in clinics, even if they don't enjoy all three. He says veterinary colleges could attract more specialists by lessening the commitment to research for those whose interests lie elsewhere. He also notes that most of these colleges are in rural areas, while many specialists live in cities and don't want to commute. "The next step may be opening up satellite clinics in nearby cities,"he says.

What colleges really need to attract specialists is funding. Without it, the lack of researchers and teachers could have wide repercussions on the profession. "I really think that's going be a problem for the profession and for the public," Hendricks says. "I think we need a national initiative to recognize that the ability financially to continue training and then work for the public good is in jeopardy."

Specialty hospitals

Florida Veterinary Specialists is a large-scale veterinary hospital with a staff of more than 120, including Spier. "We have interns, visiting students and residents, so I get my teaching fix," he says. "Most every specialty is represented, so it feels academic."

Similarities between the academic environment and veterinary hospitals may be the chief reason many specialists are attracted to large-scale facilities. Dr. Anthony J. DeCarlo, VMD and co-owner of Red Bank Veterinary Hospital (RBVH) in Tinton Falls, N.J., says several of the specialists he employs used to work in universities. "They have the clinics, they have the salaries and they get to teach," he says. "They have the best of both worlds."

DeCarlo says he also must cope with a limited number of applicants since, even with their increased numbers, specialists still represent only 9.7 percent of the estimated 87,783 U.S. veterinarians, according to the American Board of Veterinary Specialties (ABVS).

DeCarlo combats this problem by interviewing applicants on a consistent basis, instead of waiting until there is an opening. "I think you're gonna see a bigger applicant pool in the next five years," he says. "You're gonna see a lot of specialists running around."

The 58,000-squart-foot RBVH, according to the hospital's Web site, is the country's largest privately owned veterinary hospital that offers primary and specialty care. It has a general medicine and surgery practice, a 24-hour emergency and critical-care service and a specialty practice, which includes avian and exotics, cardiology, critical care, dentistry and oral surgery, dermatology and allergy, internal medicine, neurology, oncology and radiation, therapy, ophthalmology and surgery. Every specialist works full-time. "[Clients] can see a surgeon seven days a week and in any business in the world, availability is No. 1," DeCarlo says.

Wayne Usiak, an architect at BDA Architecture in Albuquerque, N.M., recently designed a 23,000-square-foot building for the Veterinary Centers of America in Sacramento, Calif. He says demand for such facilities has been tremendous since about 2000, partially because physical plant costs are so high that specialists must share buildings to be the most economical. However, large facilities comprise just 9 percent of practices where specialists work, according to the AAHA December 2005 Specialty & Referral Veterinary Practice Benchmark Study.

Goebel says there is no proof that these businesses are more cost-efficient than smaller practices long-term. Average revenue per specialist in small, medium and large facilities spans a reasonably narrow margin of $555,000 to $504,000, decreasing as the practice grows in staff size, according to the 2005 AAHA study.

Goebel says part of the reason for reduced profits is the high compensation for specialists and other employees. "I've had some reports that [indicate that] many of the large groups as a business are struggling to get by, but the people who work there are doing well because of the high level of compensation," he says.

A changing environment

Working with specialists can be invigorating for general practitioners because they have access to stimulating cases and high-tech procedures. In addition to teaching in-house at FVS, Spier also instructs local general practitioners. He says both academic and private-practice specialists should work on developing good working relationships with general practitioners to minimize conflicts over perceived competition. "There needs to be recognition that we're all on the same team and we have common goals,"he says.

Most specialists and general practitioners agree that the growth of specialty practices has benefited the veterinary profession as a whole. Dr. Heather Weihl, DVM, says she has only had good experiences with the specialists she works with on a regular basis at Elliott Bay Animal Hospital, a primary-care center in Seattle, Wash. "It has made our lives wonderful," she says. "It's only to our advantage to have the best possible care available."

But it is the clients and patients who benefit most from the rising number of specialists. Having a specialist increases the quality of treatment and number of animals a clinic can see, especially animals with more serious conditions, such as cancer, heart defects and neurological problems.

And, with the changing landscape of veterinary medicine, specialists are driven to achieve by something they haven't really experienced before: competition. "It's healthy," DeCarlo says. "Competition is a motivator. I think the way the trends are going, the quality of care will just get better and better."

Elizabeth Rhodes is a graduate student at the Medill School of Journalism at Northwestern University.

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