General practitioners, specialists address ethics of referring cases

It's about quality of care

By Barbara R. Gores, DVM, dipl. ACVS

Southwest Veterinary Specialty Center

Tucson, Ariz.

The article entitled, "Doing the right thing" in the May issue highlighted the ideal basis of the referral relationship between the general and specialty veterinarian. Despite many veterinary management articles that push the message to general veterinarians to keep those revenue dollars in-house, referring a case to a specialist is not about competition. It is about a team-approach to patient care. The specialist provides services as an extension of the general veterinarian's practice to assist the general veterinarian in providing the best possible care for their patient, whether this is for overnight monitoring in a 24-hour facility or for a second opinion on a difficult case.

Nothing destroys the veterinarian-client relationship of trust faster than when a pet owner feels that they were not offered all the possible choices of care available for their pet. An offer to refer a case when needed sends the strongest possible message to a pet owner that his or her veterinarian has the pet's well-being as his or her top priority.

You presented a non-threatening, logical viewpoint that really represents the feelings of the majority of specialists and probably many general veterinarians who have developed successful referring relationships with the specialists in their community.

Disastrous outcomes

By Ronald M. Bright, DVM, MS, Dipl. ACVS

Loveland, Colo.

I read with great interest the article "Doing the right thing." It reminded me of some of my experiences after nearly 25 years of doing referral surgery at various universities and, most recently, in private practice.

I have unfortunately witnessed numerous situations where lack of referring a case to a specialist has led to less than optimum care for our patients and, in some cases, a disastrous outcome. The "bottom-line" in some cases clearly seems to get in the way of providing optimum patient care due to not referring a case when it is appropriate.

Furthermore, isn't it contradictory to the oath we took at our graduation ceremony where we pledge to do everything we can to ensure that the welfare of the animals we care for is foremost in our mind?

Can this system afford specialty care?

By Will Fuller, DVM

I enjoyed reading your recent article on ethics. You traveled a wide road of contemporary ethical issues, some of which deeply concern me.

A little personal background is important to understand fromwhere my remarks are coming and from where I believe the profession of smallanimal medicine may be going. I graduated in 1972 from veterinary school anddid a small animal internship after graduation. I have since been in privatepractice all but for my internship. I have a master's degree inveterinary physiology.

As a trained intern and on, I believe I became a very competentpractitioner in medicine and surgery. I believe I still am very well trained ina wide spectrum of medicine and surgery. Back when I was trained, there werevery few specialists. Specialties of surgery, neurology and ophthalmology werejust coming into their own.

Back when I started out in veterinary medicine, small animalprivate practice was strongly based on high volume wellness practices. It stillis but far less so for the more successful practices.

It was obvious to me that the more procedures you were competentto do the greater the growth opportunity you had to build the practice. If yourpractice were able to do many involved procedures, your existing clients wouldrefer their contacts to your practice. The more available you were to do theseprocedures, the more contacts were made to your practice. I believe that stillis true today.

It was a bigger volume business at lower costs than what we seetoday. Let me point out that animals were quickly euthanized for some of themost unreasonable reasons, cost of service being the number one issue.Thankfully for the animals and the profession, the companion animal has becomefar more socially important to the owner and due to this attachment andaffluence, the owner is willing to spend far more money than ever before formedical care.

Today, many articles have been written on the low pay forassociate veterinarians. How can a practice pay an associate veterinarian alarge salary unless he or she produces income to match the salary? Wellnessexams are dwindling since reduced vaccine recalls are and will reduce theimpact of bringing in clients for routine exams, try as hard as we may to getthem to come in for annual visits otherwise. Fewer contacts are being made.There are more veterinarians to compete for the pie.

We have an ever-increasing population of specialists entering theprivate sector of practice. With that population is the new business plan onthe block, the emergency specialty practice. The emergency specialty practice,as Dr. Kipperman would like to see evolve, would economically threaten themethod of my general practice.

Veterinary authors and CPAs tell us the general practitioner mustbe able to provide in-depth medical and surgical care. How can you do that whenyou have a specialist in your backyard who says "send them to mebecause you are not qualified to do a given procedure? You are not aspecialist." (Even though I probably have performed far more of certainprocedures than a young specialist.) How can you do that when you have anemergency practice that tells your clients that the animal can't betransferred back to the originating practice for one reason or another? Who ishungrier, the general practitioner or the emergency specialty practices? Arethey doing such for the welfare of the animal and client or the welfare oftheir pocket book? Probably both!

I believe that the specialty emergency practice works on adifferent business premise than the private general practice. The generalisthas to provide, in the eyes of the client, a reasonably priced service. Wedon't want to price the client out of the market. We want the client tobe satisfied and then to feel he or she can afford to return many times in thefuture. The specialty emergency practice is a one hit contact. Price is not amajor concern to return business. (However, I have known clients to refuse tobe referred to certain institutions because of previous cost experiences.) Mostspecialists will never see a patient more than once. (Correct me if I amwrong.) The animal owner has very little choice. It is either an emergency or apressing elective procedure for which they have little or no time to comparecosts. How many clients would be willing and able to return for medical careonce spending many thousands of dollars on an illness?

The more common method of compensation for hired specialistveterinarians is to pay a percentage of gross income. Is it then in the bestinterest of the specialist to work a caseload to the hilt even though on apercentage basis it may not be necessary?

In most cases, there is probably no fault in the service butmaybe overkill, i.e. a grade two mast cell tumor. Ultrasound, bone marrow tap,radiographs, splenic needle tap, buffy coat, AgNor pathology: Is that goodbusiness practice? You bet! Is it ethical? Tell me your thoughts. I am led tobelieve that a finite amount of income is associated with each animal that is sentto an emergency specialty practice never mind the general practitioner.

You say that "Practitioners lose the trust of far moreclients by not offering referral and proceeding forward with procedures he/shewas best not equipped or qualified to perform by choosing a low-risk optionfor the client and pet that ensured a mediocre outcome." I don'tagree with this statement. Practitioners lose the trust of the client by notknowing what are the available options for care and fail to help the animalowner decide what is the best for the companion animal bond in question.

You stress what is the best care for the animal is foremost. Ibelieve you are failing to address the reason for our existence as companionanimal veterinarians. We exist to help maintain a companion animal bond. Thattakes into consideration the affordability of services, the level of servicesan owner chooses regardless of cost, the social desirability to live with acompanion animal and the affection of the animal to the owner.

I am an advocate for the best medical care. I strive to providejust that. I also believe the best and more appropriate medical care does notalways have to be provided by specialists or at a 24-hour emergency service. Ihope that veterinary medicine does not go the path of human medicine where wehave educated far too many specialists than the system can afford.

Disparate set of views

By Rene Gandolfi, DVM, dipl. ABVP

General practitioner

Castro Valley, Calif.

After reading Dr. Kipperman's article "Doing the right thing" and some of the responses that were received, I find it interesting that the three veterinary specialists (all surgeons, I might add) were entirely sympathetic to your concerns, whereas a "generalist" took issue.

I question what might be the reason for such a disparate set of views. It seems to me that most "general practitioners" rarely, if ever, encounter a case that was grossly mishandled by a colleague, whereas referral specialists will usually see the most difficult cases and therefore the ones most likely to be mismanaged. Could it be that it is from these experiences that you and your fellow specialists have become more acutely sensitized?

Specialty practice is, by its very nature, one wherein the veterinarian knows his or her limitations and consciously defines them. The generalist, as Dr. Fuller points out, can neither afford to create such limitations, nor is it appropriate for him or her to do so. The result would really be the nightmare that he fears, one where the pet owner pays more and more for less and less convenience and care.

I don't, however, see that specialty practice, be it an ophthalmologist, surgeon or a critical care facility, will threaten my practice or that of any other competent and dedicated veterinarian. No more so than if an equal number of well-trained generalists with a modicum of business savvy were to move in down the block.

If my client wants me to deliver the care, if I have the training and expertise, and if the medical circumstances of the case determine that I am able to serve the client and the pet in a competent and ethical manner, then the case is treated "in house". If the client would rather consult a specialist, it is his or her choice to take the case elsewhere. Do I offer referral for each and every case? No I don't. When I am familiar with the diagnostic work-up for a presenting problem, when I know my care can provide my client and my patient with the desired outcome, management or resolution of the condition with the least risk and discomfort to the patient, I don't offer referral. However, if, by the very nature of the condition, my patient would be better served by seeing a specialist, the case should be referred, just as it should be if I don't have the skill or training in this particular condition or species. What do I mean by "the nature of the condition"? For example, any patient that requires 24-hour veterinary monitoring gets referred because I don't have a doctor in my building watching cases in the middle of the night. And if I fail to inform my client that such services are available, I'm just not practicing the type of medicine I want to be proud of providing.

Competitive advantage

By Randy Willer, DVM, MS, MBA, Dipl. ACVS

Loveland, Colo.

I have owned and managed specialty practices for 12 years and emergency practices for the past six years, and I have first-hand experience with many of the issues discussed in the article.

Being an advocate for the best medical care available sometimes means referral to specialists sooner than later and to facilities offering 24-hour care.

Those that subscribe to offering clients this option and who also have great relationships with specialists can differentiate themselves for competitive advantage that, in turn, results in increased profitability.

There is a rift

By Duane Flemming, DVM, JD, Dipl. ACVO

Pleasant Hill, Calif.

Dr. Kipperman's article "Doing the right thing" discusses some aspects of veterinary referrals and in doing so brings to the forefront a rapidly developing rift in the fabric of the veterinary community.

The rift I refer to is the evolving, and sometimes not-so-friendly, competition between the general practitioner and the specialist; the gradual creation of the veterinary equivalent of a modern day Hatfields versus McCoys.

The response letters to Dr. Kipperman's article are illustrative of that rift.

The letters from Drs. Gores, Bright and Willer, interestingly enough all board-certified veterinary surgeons, represent the typical specialist view that the "best" or "optimal" veterinary care is most likely to be found with a specialist or at the referral center.

They universally argue from the apparent ethical high ground that early and frequent referral to a specialist is in the best interest of both the patients and the general practitioner while suggesting that, at least in some cases, a failure to refer is based on preservation of the generalist's "bottom line."

The subliminal message is, of course, that consideration of the "bottom line" represents a conflict of interest with "optimum" patient care and is therefore, and somehow, a little less ethical. These specialists, however, do seem to leave out the fact that they are in business and, like the generalists, profit, sometimes greatly, from these patients.

The generalists, as represented here only by Dr. Fuller, also attempt to capture the ethical high ground by arguing that they are concerned with providing the "best" medical care for their patients. He argues that the generalist, because of the ongoing nature of their patient care, stands on somewhat higher ethical ground than the specialist by being concerned with and thereby preserving " the companion animal bond" and the "affordability of services." Dr. Fuller then goes on to present what appears to be the real bedrock source of the rift, that the specialist and the referral centers represent "more veterinarians to compete for the pie" and thereby "economically threaten the method of my general practice."

It appears to me that, in reality and despite the rhetoric to the contrary, both sides are fundamentally the same. Most generalists and specialists genuinely do care about the well-being of their patients and their clients. Both are in business to make money and support themselves and their families, and both are necessarily concerned about the "bottom line." And, like it or not, both are competing for the same client dollar.

So if everybody is in the same boat, how come the rift? The rift is, I believe, the inevitable result of a rapidly changing profession that has not had sufficient time or opportunity to reflect on and then develop an appropriate etiquette for referrals.

Dr. Fuller is right in that the veterinary profession is going the way of the human medical profession by producing ever more specialists. That is not necessarily a bad thing. We are going to have to deal with it. These new specialists and their referral centers do indeed take a "cut of the pie." But, the specialists are also right in that many generalists hold on to their "cut of the pie" a little long, sometimes to the detriment of the patient and/or client. We need to deal with that as well.

In my view, both sides need to recognize the position and value of the other. The specialist needs to recognize that the generalist is a skilled practitioner and not a glorified traffic cop serving only to direct patients and their paying owners to the appropriate specialist.

The generalist needs to recognize that in some cases the specialist can provide a higher level of care to those patients that need it and those clients who want it.

Both sides need to remember that they are professionals and put the needs of the client and patient ahead of their financial interests. In addition, the profession as a whole needs to develop a realistic and practical business model for both general and specialist practices.

Veterinary medicine, from either perspective, is not retail business nor is it human medical practice. We need to find our own identity and work out our own etiquette to ensure that we really are providing at least the opportunity for the "best" medical care for all our patients. Dr. Kipperman's article and these responses should help us progress toward developing this etiquette and hopefully closing the rift.

It's a different world

By Bernard E. Rollin, Ph.D.

Veterinary ethicist

Colorado State University

Dr. Kipperman's article underscores the point that many veterinarians are practicing in a different world now than they would have been practicing in when they first entered the field.

Back in the late 1960s, there were few veterinary specialists outside of veterinary colleges. Those who were in practice were almost always in large urban Cadillac practices such as New York's Animal Medical Center that tended to serve the wealthy.

By and large it was at that time perfectly appropriate for the average practitioner to worry about the client's financial situation, since most people limited the amount of money they would spend on a pet.

Today, however, increasing numbers of people see their companion animals as "members of the family" and friends. It is no longer shameful to grieve for the loss of a pet; custody of the dog or cat may be a greater issue in a divorce settlement than custody of the children.

We now realize that a companion animal may represent the only reason for an old person to get up in the morning; the only friend a newcomer to a city like New York has; a social lubricant for meeting other people; a child substitute for childless couples. With this new status for animals come new challenges for veterinarians-the need to rethink their assumptions about what clients will spend; the need to see the increasing numbers of specialists as teammates, not opponents; the need to provide more time to clients to discuss all options.

At the same time the specialists must remain in communication with the general practitioner for a variety of reasons, from assuring compliance with regimens to management of the animal in the context of family lifestyle and dynamics.

The letter from Dr. Fuller illustrates the real concerns that an established general practitioner may have about the proliferation of specialists. It is true that general practitioners can no longer count on vaccines as a way of chumming the waters. But there are many other avenues open to attracting clients.

Indeed, Dr. Fuller mentions specialists in human medicine. Most patients who are ill enough to go to specialists do not feel that these specialists replace a good general practitioner. Specialists do not know you, do not know your family situation, do not manage the whole case in a way that prevent iatrogenic problems that arise from different specialists each treating their own niche. The same is true in veterinary medicine. A general practitioner with extensive knowledge of a family is far more likely to help a family adjust to a dog with arthritis than a specialist is.

General practitioners have been slow in accommodating needs they can fill, such as educating clients on what is entailed by getting their first pet. One of my colleagues has hours one evening a week to advise prospective pet owners. They may think they want a Rottweiler; he shows them that a cat is more congenial to their lifestyle-they are clients forever! Another colleague in general practice has a boarding kennel that provides training while people are on vacation.

Specialty practice can be a help to general practitioners, not a threat. The same social forces that have driven the market for specialists can be a boon to general practitioners open to innovative thinking.