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Leading Off: Making the most of specialty referral services
Deciding when to refer is not always easy.
Several years ago, I received a call from a relative living on the East Coast. He had just found out that his elderly Yorkshire terrier had kidney failure, and the dog's primary-care veterinarian had given my relative little chance for hope. The veterinarian had told him the only option was euthanasia and hadn't offered consultation with a specialist. Recognizing that more could be done for this dog and knowing the owner's willingness to pursue any reasonable course, I contacted a referral hospital in that area, and an internist agreed to see the dog. My relative's dog survived another few years after successful therapy for leptospirosis.
Kenneth R. Harkin, DVM, DACVIM
Why did the primary-care veterinarian fail to refer in this case? The dynamics of that situation will never be known, but it is clear that neither money, distance, nor client stubbornness was preventing the referral. This client wanted his dog to receive the best care possible.
TO REFER OR NOT
The question of when to refer a patient to a specialist frequently has an easy answer. Complex pelvic fractures, a ruptured anterior cruciate ligament, cataract surgery, balloon dilation of an esophageal stricture, and transvenous placement of a pacemaker are all examples of conditions that one would prefer were handled by a board-certified specialist.
Unfortunately, deciding when to refer is not always that straightforward. Specialists frequently see patients whose condition has deteriorated, sometimes to the point of becoming a terminal illness, for many reasons, including an incorrect diagnosis or suboptimal treatment. Often the primary-care veterinarian has suggested referral only to have the client decline month after month and then finally agree when it's too late. However, sometimes a referral is never offered, even when the results of routine diagnostic tests are inconclusive and the patient's condition declines with empirical therapy.
So what does a specialist offer? The tangibles are obvious: advanced diagnostic evaluation, such as computed tomography (CT), magnetic resonance imaging, ultrasonography, and endoscopy; technical expertise and the latest techniques, such as phacoemulsification, total hip and knee replacement, tibial plateau leveling osteotomy, balloon valvuloplasty, and radiation therapy; and 24-hour care in most specialty hospitals. The intangibles are difficult to quantify, however. Sometimes it just takes a different perspective to uncover a cryptic diagnosis.
The following is a list of the main reasons primary-care veterinarians refer cases to specialists:
• 24-hour care is needed. Patients with spontaneous or traumatic pneumothorax, diabetic ketoacidosis, acute necrotizing pancreatitis, acute renal failure, splenic hemangiosarcoma, or gastric dilatation-volvulus, for example, need round-the-clock care. For these patients, telemetric electrocardiographic monitoring, routine measurement of central venous pressure and urine production, and early intervention of complications can make the difference between life and death.
• Necessary diagnostic tests are unavailable in general practice. Although this is probably the most overrated reason for referral, it is often the hook that convinces a client to pursue the referral. The client often easily accepts that his or her dog needs abdominal ultrasonography, gastroduodenoscopy, or a CT scan.
However, the real value in the referral comes from the added evaluation by the specialist who may uncover historical information, a physical examination finding, or another diagnostic clue that had not been considered. It may result in the recommendation of a diagnostic test that differs from the one recommended by the primary-care veterinarian. For example, a dog that was referred to me several years ago for a liver biopsy never underwent the procedure because I obtained an extensive history that revealed that the client was unknowingly poisoning her dog and husband with comfrey, which she was making into a tea. Regardless of the anticipated procedure to be performed, the goal is always the same: Provide the best possible care to the pet.
• Advanced surgical or procedural skills are required. We all should be cognizant of our ability level when it comes to surgery and recognize when a procedure should be left to someone with more training. Procedural complications can happen to anyone, but when they happen to a general practitioner, the question of whether the surgery performed exceeded the veterinarian's expected skill level may be raised. However, this question cannot be raised when a board-certified surgeon performed the surgery.
Recently, a veterinarian asked me if I thought he could instill clotrimazole into the nasal cavity of a dog with suspected nasal aspergillosis without performing rhinoscopy. Assuring him that this approach would not work and after successfully encouraging him to refer the patient, I spent two hours endoscopically removing fungal plaques from this dog's nasal cavities and frontal sinuses before infusing clotrimazole. The entire procedure took nearly four hours, but the dog was cured after just one treatment. That kind of time investment would not be cost-effective for a general practitioner.
• A diagnosis remains elusive. In the absence of a diagnosis, how long do we give empirical therapy before realizing that the case exceeds our diagnostic abilities? In some patients the answer may be 24 hours, in others it may be four weeks. General practitioners are expected to know about a lot of things, but they are not expected to have the same level of expertise as specialists trained in ophthalmology, dermatology, cardiology, internal medicine, or any other specialty. And although specialists can't do it all, they are proficient in their area of expertise. Clients are often surprised when a diagnosis is achieved in one day for a problem that has eluded definitive diagnosis for weeks. But the value of the collective expertise in a referral practice along with the contributions of the primary-care veterinarian has to be appreciated.
Sometimes no diagnosis can be achieved, but that should also reassure the primary-care veterinarian. And knowing what the problem isn't can lead the specialist to make additional recommendations for empirical or symptomatic therapy that may resolve or palliate the patient's signs.
Sometimes referring is not an option. A client's financial constraints, the distance to a referral center, and a client's refusal to accept the referral are common reasons. I spend a lot of time on the phone consulting on cases with primary-care veterinarians. Most of the time, all that is needed is someone to bounce ideas off of or to concur with the diagnosis or treatment plan. Sometimes it requires a reassessment of the history or test results.
Phone consults are fraught with limitations, however, such as the inability to see and touch the patient, view the radiographs, and question the client. Just because an answer is not readily obtained over the phone does not mean a diagnosis cannot be achieved if the patient is referred to the specialist. In fact, when possible, this situation should prompt the primary-care veterinarian to encourage the client to seek the referral.
MAXIMIZE YOUR TEAM POTENTIAL
Board-certified specialists are an important part of the veterinary healthcare team and should be used to their maximum potential. The American Animal Hospital Association recently developed guidelines to help companion-animal practitioners and specialists communicate optimally and enhance referral relationships. You can read the guidelines at www.aahanet.org/PublicDocuments/AAHAReferralGuidelines.pdf.
Clients are becoming more demanding, and the Internet has opened up their eyes to what is possible and expected. Clients appreciate that the primary-care veterinarian has the patient's best possible care in mind when a timely referral is made and will remain loyal clients in the future.
Kenneth R. Harkin, DVM, DACVIM
Department of Clinical Sciences
College of Veterinary Medicine
Kansas State University
Manhattan, KS 66506