After yesterday’s post on how to spy quality in veterinary care, I received an email asking this simple question (and I paraphrase): How do I know if my veterinarian should be referring me to a specialist? What are these “complex” situations you allude to in your post and how would I know if I’m being led astray?
Excellent question! More so because there’s no clear answer. While our leading professional organizations have issued guidelines for what constitutes a specialist and when veterinarians should refer to specialists (reference the American Veterinary Medical Association and the American Animal Hospital Association, respectively), they’re loosey-goosey at best on the particular circumstances in which a veterinarian should recognize his or her limitations and offer the services of an expert.
So where does that leave pet owners who really need to know when it’s best their pet see a specialist? Kind of in limbo, I would think, considering that every veterinarian has their own personal philosophy on this issue. And because this is my blog, I’ll offer you mine.
To that end, here are the top ten problems for which I recommend specialists:
#1 Any second opinion.
Do not pass go. I will see new clients for a second opinion but I won’t usually charge them for the ensuing discussion if what they truly need is a specialist. And they usually will if they’ve got a problem their regular veterinarian was unable to solve. Here’s where it’s obvious their regular veterinarian should have already done the same rather than lose a client to another hospital.
#2 Any lack of trust (a corollary to #1).
So should you fail to trust your veterinarian when it comes to a diagnosis or treatment option, don’t see another general practitioner. Head on over to a specialist. The only caveat is that some specialists require your veterinarian’s referral. In this case you’ll have to ask your veterinarian to refer you. If this makes you uncomfortable (or should your vet refuse), well then you’ll have to come see someone like me first. Unfair, yes, but sometimes necessary––unfortunately.
#3 Any legal matter.
I will not knowingly engage in any potentially legal dispute between a veterinarian, individual or enterprise and a client without offering the services of one better suited than myself to serve as an expert on the matter in a court of law.
This is especially true for necropsies (post-mortem studies), for which I’ve determined my expertise is typically inadequate (given the degree of detail legal cases tend to require). Clients sometimes get upset at this but I’ll absolutely refuse to necropsy any legal case. Instead, I’ll happily help them ship the body to an appropriate pathologist.
#4 Any orthopedic surgery or thoracic surgery.
I’ll do ‘em if you have no other choice due to the expense involved but clients need to know they ALWAYS have better options. Orthopedic and thoracic surgeries are ALWAYS best performed by a board-certified surgeon. That’s because the literature has repeatedly shown that experience is directly proportional to outcomes in these cases. And all but the most newly minted surgeons have more experience with these cases than any generalist. After all, they do them every day.
#5 Any exploratory surgery.
I’m happy to perform exploratory surgeries as long as you understand that if I find something I can’t manage (because I don’t have the equipment or the know-how), I might be closing your pet up only to send you to the specialist anyway. btw, we call this a “peek and shriek” surgery. And nobody wants one––least of all your pet.
For example, I don’t think you want any general practitioner removing liver lobes or kidneys, reattaching intestines to the stomach or even touching the colon anywhere with a knife. And even some foreign bodies (though rarely) that I’m happy to cut might require either of the two latter procedures. That’s why I always offer a specialist––as in: “I’ve done dozens of these surgeries but you need to understand that if I find something unusual or if there’s severe infection present it would be better for you to be at the specialist’s place. It’s ALWAYS a risk.
#6 Any time it takes more than a trio of visits to solve a problem.
With few exceptions (and there are a few) any problem that requires more than two or three visits to solve gets offered a referral. This is especially true for dermatology and ophthalmology (severe allergies, non-healing corneal ulcers, etc.).
#7 When better equipment is required.
Sure, I can test for all the basics but you can’t expect me to offer every single bell and whistle in modern veterinary medicine’s arsenal. Ophthalmologists, internal medicine specialists, cardiologists, surgeons, neurologists, etc. They all have better equipment your pet might need.
#8 Any heart murmur.
I know this isn’t a popular opinion among my colleagues but ANY time I hear a heart murmur or cardiac rhythm abnormality (especially in a very young animal) I will offer the services of a cardiologist for a physical and echocardiogram. Many times I will perform the EKG and X-rays in-house and send the strip/images to the cardiologist along with the patient. While most of my clients decline this step due to cost concerns (cardiologists are not cheap), it’s always on offer.
#9 Every X-ray or ultrasound image.
Again, not a popular opinion, but it’s my take that every X-ray or ultrasound image should ideally see a radiologist or another appropriate specialist (surgeon or internist, usually, as these specialists also interpret complex images constantly).
#9 Every time critical care is required.
This goes for all my complicated diabetics (and more than half my diabetics fall into this category upon initial presentation). Complicated Addisonian’s or Cushings disease cases (again, more than 50%) or any animal that requires vigilance overnight. High fevers, respiratory problems, cardiac arrhythmias, non-routine post-operative cases: they all do best under 24 hour watch.
***
By the way, when I discuss specialists I’m ALWAYS talking about board certified specialists. Back twenty years ago it was more reasonable to refer to veterinarians who limited their practices to a specific discipline (surgery, dermatology, ophthalmology). Now that boarded specialists are readily available there is NO excuse (beyond the price factor) to see a non-boarded specialist. And in my area the prices are comparable. NO excuse.
Yes, we do indeed recognize that not all our clients will be able to afford a specialist. Nonetheless, it’s my view that to fail to offer the choice is an ethical/procedural lapse my profession needs to address with more explicit guidelines. Barring that, it’ll have to come down to the Boards and the courts should veterinarians fail in their duty to offer their clients all options.
Add Comment52 Comments
Your posts yesterday and today are among those "timely" posts. I have a dog who just had a mouth mass removed about half an hour ago; she's 12 and has a really scary-sounding heart. I'd have been terrified to let them send her for surgery today if we hadn't already had a cardiac consult in the spring that suggested she'd be okay. The cardiac consult wasn't that expensive, really...and the process was quite interesting, as they hooked up the leads to my dog and the reading apparently printed out at the other end of the phone line.
(And then when I talked to the surgeon, he said she'd been so quiet this morning that he'd managed to remove it without general anesthesia ANYway, so hey. Now we just wait on histology.)
Galadriel November 17th, 2009 09:32:40 AM
I wish my vet would have let me know I could consult back with him after I went to a specialist. I was pressured into an expensive surgery with limited results by the specialist. If I had known it was OK to call my regular vet back after the consult to talk it over, I probably would not have spent my time and money on eye surgery that did not do what I had been told it could. I would have just had my regular vet take the problem eye out for less than half the price of saving an eye that really can't see.
teri November 17th, 2009 09:40:26 AM
teri: I do this for my clients. I tell them to call me if they have any questions about what the specialist recommends.
This is an integral part of what we do. That's why my post yesterday intimated that general practitioners shouldn't simply refer to specialists, they should have a great working relationship with them so there's a fruitful back and forth.
I buy my nearby specialists lunch every once in a while. You'd be surprised at how much "free" advice and goodwill this buys. And I believe it brings better care to my patients. Human nature.
Dr. Patty Khuly November 17th, 2009 09:55:19 AM
This may be a "rookie" question, or one that has been answered before, but how do you know if your vet is trustworthy? How do you find one that is?
If I were going to a human doctor and using my insurance, I can pretty much take everything they say at face value. Sure, run the tests, I don't care, it isn't coming out of my pocket. The story is completely different at the vet. I want the best care possible for my dogs, but I can't go in "with all guns blazing" if there is a problem. This is not to say that I don't want to - I just need to be conservative and take one thing at a time. I may end up consenting to everything on the estimate, but not all at one time.
So when the vet comes into the room with an estimate, telling me that my dog needs each and every item listed as soon as possible, how do I know?? I can pick and choose what I want to do based on my life experience, but I am not a vet, so I don't really know. It is like pulling teeth to get them to give me a more conservative plan of action.
Lyndsay November 17th, 2009 12:04:50 PM
Excellent follow-up to yesterday's top ten. Considering all of our Tripawds members need a specialist of some sort – usually veterinary surgeons or oncologists – a link back to this post will do them good. Thanks!
tripawds.com November 17th, 2009 12:33:42 PM
Just the ones I can relate to:
* Heart Murmur. For one cat the vet thought she heard a heart murmur when he was a kitten. We later brought him back for them to observe (don't remember the exact details) and the murmur was not heard again, neither has it shown up for any of his later exams (he is now 5). For the second cat, we were at the ER for an ultrasound (mistake as he wasn't boarded but our regular vet couldn't get him in the schedule) and the ER vet thought he heard a heart murmur, possibly related to a combination of drugs (mirtazapine, dolasetron). In talking to our regular vet we dropped the dolasetron, but the murmur has never been heard again. So, we did not do any additional follow up.
* Ultrasound - yes!! Our vet always uses a boarded radiologist that travels to their clinic. Somehow we had the bad situation where we were referred to the ER vet (not boarded) when the radiologist was unable to get it scheduled. When the backup vet at our normal clinic looked at the ultrasound notes from the one performed at the ER, she pointed out from his wording that he did not really know what he was doing. Also, we lost all ability to track progress for this cat (he had two previous ultrasounds). So, yes, will always stick with the boarded radiologist. Because the radiologist travels to our regular clinic, our vet is very involved with the process and works with the radiologist to interpret. I think the volume is pretty high as the radiologist seems to visit once a week.
*X-ray - I've been very comfortable with the the x-rays done by our regular vet for GI issues, and more recently for arthritis. Also, for digital dental x-rays. They do not consult out this service. Our vets are ABVP feline so they have seen a lot of these.
* Exploratory - Our vet said she "could" do our cats exploratory but referred us to a boarded surgeon. I think it's the right decision. He was in the best hands.
* Multiple visits - Well, with two cats with IBD and pancreatitis it can sometimes take more than 3 visits, but so far have never felt the need to go to a specialist. For us, it's been the right combo of owner that knows cat the best and watches like a hawk, and the vet who so far seems very able to handle GI disease. If one of them develops lymphoma, I'll decide then, or if one develops more acute pancreatitis.
Jenny November 17th, 2009 12:36:18 PM
Lyndsay,
i went through several vets before finding one that I like and trusted. My key was when I visited him for a second opinon on one of my cats newly discovered heart murmurs. The initial vet panicked and instiled that panic in me, demanding I do hundreds of dollars of blood work, chest xray and ultrasound. Stunned, I left feeling like I was signing over my life savings. The second opinon vet calmly walked me through my options which ranged from do nothing and we'll monitor it to a visit with a cardiologist for physical and EKG. I just felt that he respected me more as a pet owner. Its probably an intuitive thing. I think thats what it was for me and I've never regretted it.
Shannon November 17th, 2009 01:41:53 PM
Great answer Shannon. "It's probably an intuitive thing." But it's also about a basic alignment in philosophies. Sometimes you've gotta kiss a lot of "frogs" before you find your prince/princess.
Dr. Patty Khuly November 17th, 2009 01:50:30 PM
Every x-ray! Really! What's next? All blood work?
Robert November 17th, 2009 01:54:48 PM
I have to disagree strongly on some of those. Xray? Really? Robert has an excellent point - if you're going to insist that xarys are evaluated by a radiologist, then bloodwork should be done by a clinical pathologist, as well as urinalysis. Exploratory surgeries, really? A problem that takes more than 3 visits to solve? Some allergy problems will take a year or more to solve because you have to do dietary trials that - when properly done - take 6 months minimum. Some skin allergies will require cultures and a variety of attempts to control itching - such as Benadryl, hydroxyzine, Zyrtec...3 visits is not even reasonable to sort out some allergies.
Out of curiousity, what do you do ALL day? Vaccines? Spays/neuters?
I didn't get into veterinary medicine to feel helpless and to send everything the least bit complex to a specialist. I love the challenge of veterinary medicine. Yes, I'll refer when needed, and I think I know when to refer. On the other hand, I look forward to the work it takes to manage a DKA patient or a bad Addisonian crisis. It makes me a better vet to handle these cases! I'm really surprised by your post.
Catherine November 17th, 2009 03:15:27 PM
Totally agree on the x-ray readings: our vet (whom we love) thought she saw problems in our cat's chest x-ray, but wisely decided to have a specialist read it, and the specialist came back saying it was fine. If the pet is asymptomatic and the x-ray is obviously normal, probably don't need to have it read by a radiologist, but if there is a problem or suspected problem, I vote for the radiologist.
Melmike November 17th, 2009 03:31:29 PM
Could you please add anytime there is a neurological/spinal problem? Too many people think paralysis or hydrocephalus or other conditions requiring a neurologist can 1) be treated by an ortho specialist or other specialist or even heaven forbid, their regular vet, or 2) just go along with euthanasia without investigating alternatives. Leading to, could you please add "almost anytime your vet recommends euthanasia without giving you an opportunity to investigate the condition and make an informed decision." Such a condition as megaesophagus comes to mind.
LacyRudy November 17th, 2009 04:04:32 PM
I did feel comfortable having our regular general prac vet do x-rays for my Lab. Maybe this makes a difference, but it was a hip x-ray to see how they were looking in there when she started showing signs of pain. Perhaps I would feel differently if there was a more serious issue.
Erika November 17th, 2009 05:08:47 PM
I agree with the neurological/back problems!! I am quick to recommend referral for thesekind of issues as usually it takes better modalities and invasive tests that I don't feel comfortable doing or interpreting.
Anyway I just sent a 'back dog' over to the specialist today. He just went 'down' last night - he was at the specialist this afternoon and getting surgery for a compressed disk. If I would have sat on that for a day or two more then there is the possibility that we can lose our surgical window.
I know what I can do and what I can't - I will at least let people know what their options are and let them decide.
J.C. November 17th, 2009 06:23:02 PM
Robert: So it goes with human medicine. With digital X-rays easily sent, you can contract with radiologists at $5-$20 per image, depending on your volume. That's cheap! The hard part is setting up the system to do it efficiently.
Dr. Patty Khuly November 17th, 2009 06:23:29 PM
LacyRudy: As to neurologist vs. surgeon on spinal or brain surgery...it all depends on the practitioner but, frankly, I'd prefer a surgeon. This is huge controversy, btw. But if it's not straightforward, I'd always choose the person with the most surgical skills.
But when it's just neurological and obviously not about a spinal lesion or an excisable brain tumor...always a neurologist. Agreed.
Dr. Patty Khuly November 17th, 2009 06:27:53 PM
Catherine: The point is that you need to give your clients a choice.
...they'll see the specialist.
It's my philosophy that anytime I'm willing to see a specialist for my own pets it's just about the right time to refer my patients with the same condition to an expert. To do otherwise would be to greedily take on challenging or lucrative cases for my own personal gain. It would be hypocritical.
I'm not saying you need to feel the same way. As I've explained, every veterinarian has a different philosophy. And mine is to remain consistent with what I'd do for my own. Do I make less money than I would if I did otherwise? You betcha. But I sleep VERY well at night.
Dr. Patty Khuly November 17th, 2009 06:36:31 PM
"boarded specialists are readily available" Really? I find 10 ACVS boarded in Greater Houston which is incredibly low for our population. After the one I used moved (rant omitted), I haven't been able to find one to see my Shiba about her second knee, let alone to get a second opinion on that twit's knee repair surgery which appears to be failing, already verified it is luxating again - less than a year after surgery. So I don't have a very favorable opinion of the ACVS at this point (and may Mark J. Davis, DVM, Diplomate ACVS 1999 fall and break his knees!).
PJB http://pjboosinger.viviti.com/ November 17th, 2009 08:35:58 PM
My cat was recently diagnosed with hemangiosarcoma (blood vessel cancer) on his leg, which apparently, while common and devastating for dogs like German Shepards, is really rare in cats. As in, a regular vet might see cases like that only once every several years and thus have little knowledge of what it entails. So, his vet did the initial staging--x-rays to make sure the cancer hadn't spread to his chest, but got a visiting specialist to do the abdominal ultrasound to see if the cancer hadn't spread to his abdominal region. And then after those tests (luckily clear), she sent me to a veterinary specialist hospital. First we had an oncologist consult. Then we had a vet surgeon consult. Then, the surgery itself, which was a success, with a biopsy showing clear edges with good clean margins. I was told by both the vet surgeon and the vet that cancers situated in places like the leg are hard to remove because there simply isn't a lot of "tissue" to work with. That, plus the rarity of the cancer, was why we were sent to the specialists. The bill for the vet hospital (not including the fees I paid to my cat's regular bill) was $2,600 for a 30-minute procedure and a top-of-the-line overnight stay. It still sounds pretty exorbitant, but I think was well worth it. The specialists also told me we should go back to my cat's regular vet in three months for another x-ray in the minute chance he might develop cancer in his lung, which is apparently the most common site for its reappearance. Which I will definitely do, thanking everyone involved for both their professionalism and special expertise.
N. November 17th, 2009 08:45:39 PM
I don't think its ever a bad idea to educate clients about the availability of board certified specialists. I don't think a lot of people realize what specialists do or what training they have.
virginian November 17th, 2009 09:13:53 PM
Catherine: YOU are the crux of this blog post.
Glad you're not bored; wish more of your patients received the standard of care.
Fedup November 17th, 2009 09:16:04 PM
Robert and Catherine have a valid point that overreferral may be a problem in veterinary medicine. Some specialists even believe so. One reason veterinarian's do not make a living wage is because they are not taught to do procedures that are more profitable than "shopped commodities" like spay/neuter and vaccine. They actually used to teach students procedures back in the 70s and early 80s. The vet teaching hospital now only produces the "gatekeepers" for the specialists. If given opportunity and training generalist vets with some aptitude for surgery can do some orthopedics like cruciates on smaller pets or ear surgeries. I guess I should have sent the unstable dog attack with open chest wound to the surgeon who was not available after hours. As an emergency vet with several yrs experience I find referral practices now dividing emergency practice between the criticalist and the surgeon. Experienced but non boarded vets need not apply!! Specialists also can overtreat cases as much as non specialists undertreat. An older Doberman patient from a clinic where I do relief work just had a $2000 neuro workup with MRI and spinal tap for idiopathic vestibular disease. Some specialists have lack of clinical judgement just like the rest of us.
Joseph Knecht
josephknechtdvm November 17th, 2009 09:26:47 PM
"They actually used to teach students procedures back in the 70s and early 80s." I take it they don't now? Well, that so explains my intuitive preference for older vets as it indicates they really do have a broader experience base even right out the school doors.
I do find #9 to be excessive. Even if it's "just" $5-20, that's still $5-20 tacked on to the bill for every image in an era when imaging is becoming more and more common.
#3 "I will not knowingly engage in any potentially legal dispute..." Sure sounds like participating in that white wall of silence...
PJB November 17th, 2009 10:16:58 PM
I applaud Dr. K for referring DKA to 24 hour places.
IMHO, keeping a DKA cat unmonitored overnight while your clinic is closed -- or for that matter, an "unregulated" diabetic of any kind -- is flat out malpractice.
You might "enjoy the challenge" but if the pet's monitoring isn't adequate, are you going to enjoy telling the owner that their pet expired overnight?
Or does it just not phase you to do that?
Good for Dr. K for liberal referring. Too many vets do surgeries beyond their level of skill because its "fun" or "challenging" and they "get to learn" or "hone their skills" all while an ignorant owner, none the wiser, assumes the vet has recommended the best course of action, and someone's pet is exposed to unnecessary risk.
The topics the last 2 days have been the stuff I think vets AND pet owners who are really interested in quality vet med can appreciate because it's all about quality of care, practising at a high level, doing the best you can. REALLY, not frontin.
Kudos! That's all we're really asking for . . .
Stefani November 17th, 2009 10:37:32 PM
PJ: are we sisters? Or the same age?
That's where I had trouble jumping in yesterday. My experience goes back to diagnosis & treatment based on observation and pre-xrays or lab work.
Was it all wrong back then? Was I just even more naive? I don't know.
Sure, I never expected spinal surgery on my IVDD dog to be done inhouse, although plenty breed club members did have it done that way.
Would anyone know to ask about all this equipment pre-requisites for anesthesia? I sure didn't know. I still have a hard time explaining to pet friends that yearly vacs aren't necessary.
OTOH, you bet if something is unusual or out of the realm of expertise--tell me! I'll hear you!
And I liked Dr. K's response to teri, yes, indeed don't throw me and my pet to the wolves you have referred to, because that relationship and outcome falls directly back to you. IOW, a referral is not BLIND, and never should be. Your PC is your pet's doctor, the specialist is your PC representative!
A breed club friend remarked the other day that she wouldn't know what to do if her vet retired. No kidding---been there, thick and thin.
Barb A./NH November 17th, 2009 10:44:53 PM
When I had a guinea pig with a lump, my regular vet refered me to a vet hospital that had vets who only dealt with 'pocket pets'. The lump turned out to be what the first vet thought, benign, however I felt better knowing a vet that deals with guinea pigs on a regular basis was telling me the same thing. I did end up taking all my guinea pigs to that second vet, however the cats go to the first vet.
When my one cat was diagnosed, via in house x-rays, with megacolon I asked for a referal to an internal medicine specialist as the probable outcome seemed grim. I had the lab work done at my regular vet, and took the x-rays with me to the specialist. There my questions were answered better, and new medication was prescribed that I could get from the regular vet that hadn't been mentioned before. So far it's been 2 years on the new medication and no enemas! The cat is doing fine, and my regular vet has started using these medications on his other megacolon patients with as much success as mine. So not only did my cat win, but other cats benefitted from my visit as well.
I think there are times to refer out but probably more of a case by case thing. I would think owner finances, how far client wants to go with it, and the familiarity of the GP vet with that problem all plays a part in the referal process. JMHO
cl November 17th, 2009 10:50:18 PM
"Was it all wrong back then? Was I just even more naive?" I was more naive then than now. I like the new technologies but think it's sad that they so often replace instead of supplement that hands on ability.
realage.com said I was 62.3 in Oct, 2008. I'm sure they're right or maybe under aging me but I'm afraid to go take the darn test again! I appreciate all my life experiences (good, bad, and ugly) but they sure come with a price!
PJB November 17th, 2009 11:38:55 PM
Catherine says
"On the other hand, I look forward to the work it takes to manage a DKA patient or a bad Addisonian crisis. It makes me a better vet to handle these cases! I'm really surprised by your post."
Where were you Catherine when I spent more than $5,000 in 3 weeks for specialists' fees, and they still managed to misdiagnose my dog's Addison's? My dog died after an "explorarory surgery" for an obstruction that was not there! That was the Internist's diagnosis after reading and interpreting the US. The ACVS surgeon concurred with the diagnosis, he performed the exploratory and my dog died 3 days after release from the surgeon after a shock/seizure.
PJB says
"So I don't have a very favorable opinion of the ACVS at this point (and may Mark J. Davis, DVM, Diplomate ACVS 1999 fall and break his knees!)."
Neither do I. And may my dog's surgeon. . .
www.alabamavetboardwatch.110MB.com
Fotini November 18th, 2009 12:20:16 AM
I think it's a dangerous trend that's happening lately.
I strongly believe that referral should be offered to clients where appropriate.
But many of the vet schools have trained the graduating students to refer anything "remotely" hard or challenging to specialists.
The reality is that there are many VERY capable GPs out there, and the reality is that there are many bad GPs out there.
The same is also true of specialists as well.
I have a great relationship with some specialists and my clients rave about them. The opposite is true of many others and my clients do not like them, even though I keep my opinions to myself. It's interesting, clients intuitively are usually quite good at working out for themselves whether the vet they have in front of them, GP or specialist, is good at what they do.
I wholeheartedly disagree with referring every single xray, exploratory surgery, orthopaedic surgery, ultrasound case etc.
To do otherwise, simply reduces the GP to a purveyor of vaccinations and simple antibiotics. If such an attitude becomes entrenched, nothing decimates the veterinary profession faster than the disillusionment that follows.
You want well rounded, general practice vets who are capable of dealing with (and well) 90-95% of cases.
I'm not sure I agree with the criteria you outlined, they seem too prescriptive and likely to result in automatons.
I think if you have smart vets, and clients willing to ask for what they want, and a good relationship between the two, nearly all the time it will be clear as to whether a specialist is needed or not.
Just my 0.02 cents.
AlexH November 18th, 2009 06:18:09 AM
AlexH: The way I see it there's enough work to go around. Because most of my clients won't avail themselves of a specialist when I list their services as one of many options, I end up doing everything eventually.
Yes, vet students are taught to refer a great deal of what comes in the door (as was I) but that certainly has not limited my knowledge acquisition or experience. Being a general practitioner in this day and age offers the best of both worlds (in some ways)...we have all the opportunities we need to deal with clinically challenging cases and our clients are offered all the options they need to get the kind of care that works for them.
One more point: to offer an option is not necessarily to refer. I think that distinction needs to be made as well. The difference is in how the message is delivered to the client. As in: "You should see a surgeon for this fibrosarcoma because my chances for complete excision are minimal" or "this cherry eye can be handled in one of three ways..."
Dr. Patty Khuly November 18th, 2009 08:45:46 AM
When my vet found an ominous mass in my dog's chest with x-ray (that she did and also had the 2 other vets in the office look at), she recommeded that we do a needle biopsy, which she also did. Cells looked malignant and she suggested that we send the x-ray and slides to the CSU veterniary oncology department for their diagnosis and prognosis, so we could be more sure what we were dealing with.
I was happy to pay the less than $100 for them to do this and they turned it around in a couple days. Sadly, their Dx confirmed cancer, hemangiosarcoma with a poor prognosis - even with surgery and chemo he was likely to get only 6-8 months. My vet said she or the practice owner who does many complicated surgeries could do it if I chose surgery, but she recommended CSU because they see these so much more.
As Dr. K indicated above, a offer of an option does not always equal a referral. I am sure my vet could have done the surgery, but I apprecaited that she gave me another option to consider.
While I decided to forego surgery and do palliative care - I was able to make what I believe was the right choice, because I had as much information as possible.
Di November 18th, 2009 10:48:35 AM
I think this interesting discussion about veterinary specialists is a great place to point out that there are also technician specialists who have undergone very specific training and an intense and difficult application and testing process to become certified as specialists.
The specialties are:
VTS (dentistry)www.avdt.us
VTS (anesthesia) www.avta-vts.org
Internal medicine, www.aimvt.com
Which includes the subspecialties:
small animal internal medicine, cardiology, oncology, and large animal medicine
VTS (ECC) www.avecct.org
(emergency and critical care)
VTS (behavior) www.avbt.net
Plus Zoo medicine technicians and Equine nursing technicians
virginian November 18th, 2009 11:36:03 AM
virginian: There's also a move afoot to license food animal "paraprofessionals." They will not be called "nurses" or "technicians" because, of course, it might offend their masculinity––if not their compensation. ;-)
Dr. Patty Khuly November 18th, 2009 11:47:17 AM
I think a referal to a specialist should be given more frequently. As Dr. Khuly says, most of her patients don't take her up on it, but it is nice to know that it is an option instead of not saying anything and keeping that information and possibly a different outcome from the client.
Connie November 18th, 2009 12:23:03 PM
"I'll do ‘em if you have no other choice due to the expense involved but clients need to know they ALWAYS have better options. Orthopedic and thoracic surgeries are ALWAYS best performed by a board-certified surgeon. That's because the literature has repeatedly shown that experience is directly proportional to outcomes in these cases. And all but the most newly minted surgeons have more experience with these cases than any generalist. After all, they do them every day."
I'll take issue with this one too. Sorry. =) Our whippets' orthopedic vet is actually "just" a GP. A GP that happened to be the track vet for a greyhound racing track, and who really knows what sports injuries look like and how best to return them to competitiveness. He's not board-certified, and I don't care one whit. I will say the proof is in the pudding. This vet showed up at a racing national last year (taking the last couple days of his vacation to make the trip) and found well over 50 dogs (under 100, but very very many) that he'd treated. We took a group photo and it was a challenge to fit everybody in. The dogs had toe injuries, muscle injuries, wrist injuries, hock injuries, and knee injuries. That photo speaks volumes about our vet's abilities. It was a wonderful moment, possibly my favorite of that weekend. Sure, all these folks could've chosen a nearby board-certified orthopedist or surgeon, but this particular vet's reputation is well-known across the US and folks drive from Canada to get his opinion. I myself will drive by a board-certified orthopedist to reach him when we pay our annual visit on Friday.
Julie in OH November 18th, 2009 12:30:30 PM
And here's the photo any vet would be proud of.
Julie in OH November 18th, 2009 12:44:12 PM
Well, poo. That didn't work. You can delete that post. =) The photos I'm referencing are at the very end of that album.
Julie in OH November 18th, 2009 12:45:36 PM
They will not be called "nurses" or "technicians"
Dr. Khuly, you made the point that animal assistants should not be called technicians. I'd like to add that veterinary technicians in the US should not be called nurses.
virginian November 18th, 2009 01:11:06 PM
FedUp:
I am not the crux of this post. I perform excellent medicine, and I am proud of the work I do. I refer when it is needed, even when there are times when I would rather keep my cases. I love my job, I work ridiculously long hours, I study when I'm NOT at work, I study when I'm AT work, and I love, love, love what I do.
In short, you have no idea what you're talking about :)
Catherine November 18th, 2009 04:59:57 PM
At my school and veterinary teaching hospital, we are constantly told "This is NOT a specialty procedure- you can do this as a GP!" Clinicians encourage us to go out into practice comfortable with reading our own cytologies, performing bone marrow aspirates and core biopsies, placing chest tubes, performing spinal taps and epidurals, performing grid keratotomies, interpreting EKGs, and all sorts of other things that I would have considered specialist procedures before starting rotations.
Megan November 18th, 2009 07:55:49 PM
Catherine: ignorance is bliss. I have no doubt you think you're providing high quality care. However, there are specialists that trained 80hrs/week making dirt for 4 years under mentors to do only a specific job - not also your vaccines and preventative health.
It's not fair you ride on the specialty taboo that referral practices refuse to provide primary care (currently with few exceptions) such as vaccines, heartgard sales, etc. Yet you do all that and (try to do) the specialist's job too.
A day of reckoning is coming. What - do you expect us to just wither away and go sell auto insurance? All I have to do is open my appointment schedule for primary care and then we're equal - Oh, except we're not - I have 4 specialty years of training beyond you...talk about a little competition benefiting the consumer!
Fedup November 18th, 2009 08:35:35 PM
Fedup: My goodness, perhaps you should think about doing just that!
Barb/NH November 18th, 2009 09:36:17 PM
Megan,
Exactly! Keep that mentality! Work hard in vet school, study hard, and learn as much as you can. I did 2 chest tubes last week, as well as diaphragmatic hernia repair in a HBC dog that is doing 100% fantastic. I also did a liver lobectomy on a dog with HCA. You CAN do those things. It takes time, practice, and work!
Catherine November 18th, 2009 10:25:11 PM
Catherine:
Nice to know that, and I will make sure that you won't practice on my dogs!
Fotini November 19th, 2009 12:19:49 AM
As a final year vet student, I tend to agree with Robert and Catherine. There is absolutely a time to refer, but I don't believe it is for every radiograph or every skin problem that takes a food trial to get to the bottom of. (PS: At my school, we are taught to do surgery and practice foreign body removals, enucleations, cruciate repairs and exploratory laparotomies in addition to spays and neuters. I would hate not to use some of those skills as a vet.)
Grace November 19th, 2009 12:54:45 AM
Stefani - in reference to your keeping DKAs overnight v. referring them - I am an ER doctor, so they are under my supervision all night until they transfer back to the rDVM in the morning. This means that they are under care at all times. I am not an advocate for leaving patients on fluids overnight without supervision. I do understand - however - that some people do not have the finances to refer to a 24 hour critical care facility or ER clinic and may choose to leave their pets at a GP for the night in lieu of euthanizing them or no treatment at all. There are many shades of gray in this issue to consider.
Catherine November 19th, 2009 02:10:59 AM
Thank you for your clarifiction Dr K. It is much appreciated.
I guess what concerns me these days is the increasing tendency of new graduate veterinarians to pretty much push referral as more or less the ONLY option for their patients.
This is where I am coming from. There has been a subtle shift in the past decade.
I think there MUST be choice. Choice in having the option for a referral, but also choice in having the procedure done in house if the primary vet is capable of doing so.
I give my clients the choice.
FedUp, I hear what you are saying, I did not go onto become a specialist but I did extra training for "dirt pay". However, the truth is, I don't think you'd really try to do primary care. Why would you? The only benefit of primary care is the opportunity to build great relationships with clients and patients and not just to see them for one problem and when that condition is resolved they go. You get to see them from cradle to grave. But financially? That'd be silly. Vaccinations, desexings and OTC products won't give you those 4 years back.
I think the truth of the matter is, there's a time and a season for all things. A good vet knows when to cut and when not to cut, and also when to refer and when not to refer. There should not be extremes of either. No one is served well at all by extremes of either.
Choice for the consumer means the choice of being offered referral AND in house options if you are competent in that procedure and well equipped.
AlexH November 19th, 2009 04:39:09 AM
"In this case you'll have to ask your veterinarian to refer you. If this makes you uncomfortable (or should your vet refuse), well then you'll have to come see someone like me first."
That's a red flag right there -run far and fast from a GP who flat out refuses to give you a referral. The only time I would be afraid of having a specialist giving a 2nd opinion to a client is if I didn't want to be caught screwing something up :) Otherwise I'm happy to have someone confirm my diagnosis and support my recommendation(s) for further diagnostics and/or treatment.
I refer out a lot of my surgical cases. I could walk a vet student through a routine enterotomy, but I can never guarantee than anything will be routine once I open a patient up. And I'm not a huge fan of the peek and shriek procedures! I wrote something about that a few weeks ago: http://levittownvetblog.com/general/finding-veterinary-surgeon/
Dennis Leon, DVM November 19th, 2009 11:42:15 AM
Dr. Leon: WELL said & ethical !
Julie in OH: the DVM for IVDD surgery, that a breed club member had excellent luck with, has relocated to Ohio some years ago. Perhaps same one.
Catherine: I am puzzled, why would a client cart the patient back & forth between ER & home clinic? Isn't that odd that the GP would want this done?
Barb A./NH November 19th, 2009 07:00:17 PM
@Barb A. -- Nope, he's in WV. He's become a friend of my family, frankly. He keeps trying to retire but he has oodles of folks begging him not to!
Julie in OH November 19th, 2009 07:26:44 PM
Barb, The 2 Animal ERs closest to me open about an hour after normal business hours and close about an hour before any of the vets open; neither are staffed during the daytime. Owners have to transport animals twice a day and tend them for that hour.
PJB November 20th, 2009 12:56:52 AM
Valentine's Day gift,there are many new style product for new year,the most time select new year gifts unavoidable to choosep90x.com, designer clothe,cheap clothes online,wholesale clothes online,buy cheap clothes,mac cosmetics,cheap mac cosmetics,cheap gucci shoes,p90x,discount mac cosmetics,cheap replica handbags,cheap designer handbags,cheap coach handbags,replica handbags , etc,welcome order here and enjoy yourself.
p90x February 8th, 2010 09:52:56 AM
Add Commment