Specialists are new graduate's ally

April 1, 2004

At some point early in a new graduate's career, he or she will stumble upon a patient case that's hardly the textbook variety.

At some point early in a new graduate's career, he or she will stumble upon a patient case that's hardly the textbook variety.

When such a scenario arises, and generalists and specialists agree that it's inevitable, both parties offer similar baseline advice: know when to refer.

When managing a complex case, the specialist may say veterinarians can't refer soon enough; while the general practitioner typically views the referral as one of several options.

But the experts agree: first consider what's best for the patient, then make the referral decision.

"If there's something a new graduate feels they can't handle, they need to at least offer the referral," says Dr. Alice Jeromin, board-certified dermatologist in Brecksville, Ohio.

Daniel Brogdon, DVM, board-certified veterinary ophthalmologist in Jacksonville, Fla., agrees that when new graduates are seeking to forge a relationship with their local specialist, his best counsel: "Refer early and often."

"When you refer a case to a specialist, it is a win-win situation in which the pet gets high quality medical care and you get the credit for the referral," he says.

But Dr. Tom Mann, general practitioner in Akron and outgoing president of the Ohio Veterinary Medical Association, says referrals shouldn't be a quick fix.

"Students need to do everything that their training and capabilities allow them to do first. If this (procedure) is something I'm not comfortable with or qualified to do, then refer it. Don't look at something right away and say I can't do this. How are they ever going to learn?"

He speaks of concerns that universities are filled with specialists, who are training students to "do nothing but refer." "They're not being taught you're going to see this broken femur, and you have the capability to fix it. Instead, it's 'you don't have any business doing this, you better send it out.' "

While he agrees there's many a time and place for referrals, he says it's imperative that students master the ability to discern that consideration.

When money's an issue

Clients' economic issues can play a negative role in the referral process, according to Jeromin. She says more than once, veterinarians have told her they "would've referred sooner, but the owner doesn't have the money."

But when she probes the case deeper, she says she's disturbed by what she finds. "The veterinarian has already run all these extraneous tests on the animal. If I had seen that patient sooner, I never would have run those tests. Who's spending that money?"

If money truly is an issue, Jeromin says she wants to clarify that she is the client's "buddy" in trying to save them a buck and advises referring practitioners to find out her true costs before making a snap judgment call for their clientele.

Adds Brogdon, "Don't make financial assumptions; let clients know if a referral is best for your patient. Let the client make the decision."

Mann agrees, "Be very careful that you don't let money make the decision – you have to advocate what's best for the pet."

Stumbling blocks

The biggest pitfall students can make when faced with a complicated case is being too confident to turn down a case, Mann says.

"Don't try to B.S. your way through something. You know when you look at something that you can do this or I have no business doing this."

Another pitfall, according to Dr. Brian Forsgren, general practitioner in Cleveland, is when a new graduate feels locked into handling only limited responsibilities, such as heartworm cases and vaccines.

"Everything that is the least complicated, (they are told to) send it to a specialist," Forsgren says. "Well, they called the dermatologist and they can't see the patient for three months. Somewhere in that in-between, the generalist and the specialist have to communicate. Their communication has to be based on what's best for the animal, the owner and the situation."

Ultimately, Forsgren says it's up to the new graduate to take the case as far as possible.

"It's 2 a.m., and you have an emergency eye procedure. No one else is around. What do you do?" he asks. "You have to know how to manage that case, and have an idea what the specialist would do. You can't use these specialists as total crutches because you're afraid."

Specialists are allies

No matter where the new graduate stands in the referral process, as a new associate, Brogdon encourages young graduates to recognize the role a specialist plays in their career: existing to serve the practitioner and his/her clientele as an extension of the referring DVM's practice.

"Don't ever think that you are bothering us by calling. No problem is too small or insignificant for the referral process. It is an outdated attitude that thinks that specialists exist only to see complicated and complex cases," he says.

Students' edge

The advantages a new associate carries into practice are invaluable to the specialist and general practitioner, according to Jeromin.

"They're coming out of the gate with the most recent techniques," she says. "They are not afraid to say, 'What's going on here? What should I do next?' They're very open to ideas."

By building a relationship with local specialists recent graduates can stay updated on the latest medical advances in the diagnosis and treatment of diseases.

Brogdon adds, "Get to know your veterinary specialist as a colleague and a friend. Once you build this relationship, communication is easier, more efficient and expectations more realistic. Both the client and pet will benefit."

The first couple years out of school are critical for the new graduate to build relationships with specialists, according to Forsgren. He says it's up to the American Veterinary Medical Association and local groups to provide leadership in mentoring new graduates and connecting them to specialists. "The greater your exposure to the generalist/specialist network, that is what will truly make great veterinarians."