Knowing me to be full of crotchety opinions in all things veterinary, a colleague recently asked me to enumerate my top pet peeves in vet medicine.
But like a foodie asked to list her least favorite dishes, I was reluctant to rank my curmudgeonly views on my own profession, especially since I do love it so, faults and all.
Still, I thought it would be valuable to pen a post on this, especially since one particular issue’s been bugging me lately. So here it is: a lambasting of veterinarians who refuse—outright refuse—to send their patients to specialists.
Veterinary specialists are growing in popularity all across the US. Among others, we have vets to cut things up expertly (surgeons), vets who deal exclusively in eyes (ophthalmologists), vets who dedicate themselves to pet behavior issues (behaviorists), and even some who spend their days irradiating tumors (radiation oncologists).
Yet there are no clear guidelines on how referrals should happen in veterinary medicine, as there are for the human medical profession. That's why some vets won't give you the choice of seeing a specialist when your pet has a condition better suited to a specialist's ministrations.
So why is it that some vets assume they can keep their patients all to themselves, refusing to let their clients know when more highly skilled, knowledgeable providers are available?
I’ll give you four reasons we sometimes refuse to refer:
1-The short-term financial health of our practices
Not referring to a specialist means we get to do more tests, hospitalize more patients, perform more lucrative surgeries, and make loads more money than we would have otherwise. In my experience, there’s no doubt this is the number one reason vets refuse to refer.
An example: In my area if there’s a surgical procedure a vet can’t perform, non-referring practices will call in a non-board certified “surgeon” to cut the case instead. Said surgeon will arrive with tools and tech in tow, perform surgery several levels below the area norm for a boarded surgeon, charge the hospital a sizable fee and leave it to manage the post-surgical case as best they can. The client will never meet the surgeon, but they’ll have been told that a [presumably board-certified] surgeon has performed the necessary procedure.
Sounds shifty, right? It is. I should know. I used to work for one of these non-referring hospitals. I was fired for insubordination, i.e., referring patients to boarded specialists and refusing to allow clients to go through surgery in-house without informing them of their broader choices.
2-Our client’s good opinion of our skills
“If she’s referring me to a specialist it must be that she has no clue what she’s doing.”
That’s what we sometimes fear our clients will say about us on their way out the door. And maybe we worry they’ll never come back if we don’t exude the confidence of a James Herriot-style vet, one who can balance the entire animal kingdom on her shoulders. Why risk referring when we can try our best and hoard our clients’ good opinion of our work?
3-Our colleagues’ opinion of our skills
Every time we refer our patients to specialists we set ourselves up for potential disappointment in our own skills and for perceived condemnation of our skills by someone who knows much more than we do.
Here’s an example: A couple of months back I referred a patient for a cruciate ligament repair and it turned out to be a bone tumor. Embarrassing? Yes. A cruciate is typically an easy diagnosis for me. I wouldn’t have begrudged the surgeon his right to think less of me in this instance.
But what was my alternative? Perform unnecessary surgery (as must happen often in hospitals with strict no-refer policies). And that would’ve been worse. In the end, it was a “no harm no foul” situation that left me a little red-faced but otherwise none the worse for it. Ultimately, the patient was well served by my referral.
4-We think our clients can’t afford it
Sometimes there’s nothing more going on than some veterinarians’ belief that you can’t afford more expensive, specialized care. In these cases, “there’s nothing more we can do” translates into no more treatment. I’m convinced pets die this way every day.
Yet YOU are the only one who can decide what you can afford for your pet.
In all these cases, YOU are the final arbiter of your pets’ healthcare decisions and you MUST be informed of your choices.
In lieu of being handed these choices on a platter, you need to learn to speak your mind, ask questions, and seek out the kind of care you want for your pet:
Ask if the specialist is board-certified. Ask if you have a choice of specialists. What are the price differences? What do you get for these? 24-hour care, etc.? Ask if there’s a closer specialist, as some vets will often refer to those hospitals they don’t think “compete” with them, often to the detriment of clients and patients who need more immediate care.
I know this is a long-winded post, but it’s something I just had to get off my chest. And it’s something every pet owner should understand before their pet suffers the “there’s-nothing-more-we-can-do” syndrome too common to some less scrupulous practices. Remember, YOU are in control. All you have to do is ASK.
Dolittler
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I must say that the last point in particular, as a rabbit owner and vet student, is one I've come across several times (luckily I've had the knowledge that there is other, more expensive options-and the vet has presumably thought, noone spends that much on a rabbit, as is possibly true most of the time)-owners need to be given options, although there is a line to be tread to word the options in such a way that the owner does not feel pressurised.
Sian August 9th, 2008 12:24:00 PM
Dr. Kuhly:
I commend you for your honesty. Unfortunately, my companion pet and I didn't have the opportunity to get all the options available to us, I didn't make an informed decision on my pet's health problems, and my poor companion died as a result of the veterinarians' dishonesty. Having said that, it was not the attending veterinarians' dishonesty, but the board-certified internist's and board-certified surgeon's fraud and misrepresentation that caused my pet's death. These two, presumably more knowledgeable veterinarians, misdiagnosed and mistreated my pet. Although there are more options and less invasive procedures, they never offered them to me. It is very disturbing that we the pet guardians (unfortunately after we loose our companions) have to turn to the internet to educate ourselves on diagnoses, treatments, procedures, and options that some veterinarians should have provided in the first place. An endoscopy is less expensive than an exploratory celiotomy (for intestinal obstruction) and less invasive procedure for a 13-year old toy poodle, but I was never given that option. I didn't know that this procedure could have easily diagnosed if there was indeed an obstruction. The surgeon found no obstruction as the internist had (mis)diagnosed, and my baby died after the surgery. His cause of death was Atypical Addison's disease and sepsis.
Fotini August 10th, 2008 01:41:00 AM
Fotini: Your comment makes me want to add two points to the discussion:
1-Specialists also need to know when to refer. The specialists I work with (at five different nearby hospitals) will often refer to one another (or to a University) when it's clear a patient will be better served by another specialist with different skills, or by a facility with specialized equipment.
2-I should add a #5 to my list above: Sometimes the complex nature of a case confounds the diagnosis and makes the next steps hard to determine. And sometimes complications happen. For example, my own dog (Sophie Sue) was first treated by an internist and a surgeon for what they thought might be an insulinoma. She had full-on abdominal surgery which yielded nothing, despite some promising tests. In the end she had a brainstem tumor which is now being properly treated with radiation. No malice. Just complexity. And complications.
Dr. Patty Khuly August 10th, 2008 09:56:00 AM
Fotini: In no way did I intend to trivialize your situation with my above comment. I don't know the details of your case but I do feel it is my job to give you my perspective where I can.
Dr. Patty Khuly August 10th, 2008 10:00:00 AM
Wow! I had no idea that vets did such things (#1)! I love my vets even more now knowing that they'll send me to OSU/MedVet when they feel it's best for my pets. It's silly for any client to think that one vet is THE expert on every species, every illness, every treatment, and every surgery.
Sarah August 10th, 2008 04:23:00 PM
Seems like what's best for the patient isn't on the list.
Failure to refer can truly harm a patient. I recall someone whose dog had a very specific type of surgery supposedly perfomed on him by a generalist vet. The staff let it slip that she'd never done that surgery before. The results were, NOT good and that's an understatement.
This is one of many cases where teh vet should have referred because the case I am thinking of involves speciality urological surgery.
Stefani August 10th, 2008 09:29:00 PM
Stefani: You raise a good point. I stay away from doing most "urological surgeries" (except for uncomplicated bladder stone cases) but my bosses are very good at these, having come of age at a time when no specialists were available. In these cases I can offer to refer to one of my in-house colleagues or to a boarded specialist. As long as clients know what their choices are and the pros and cons of each that's OK.
But there's more interesting stuff behind your point, as well. What about the level of experience of the vet? Does a doc need to disclose how many procedures they've done before before trying it on a patient? Not necessarily.
Take the example of a surgical resident in a human hospital setting. You're not always told who actually did most of the cutting when you have your gall bladder dealt with in a human teaching hospital. After all, residents must learn on someone. But if you're a smart patient, you may indeed specify that you don't want the resident working on you.
No one's trying to pull a fast one here. That's just how docs learn. But it's another example where knowing how things work in healthcare can get you better care.
Savvy patients/clients ASK how many such procedures the doc has done before. In these cases our ethics oblige us to answer you honestly.
Dr. Patty Khuly August 11th, 2008 08:16:00 AM
Hello Dr. Patty,
Excellent blog (as usual). :0) I wanted to pass you along the AAHA Referral Guidelines you may find useful. http://www.aahanet.org/PublicDocuments/AAHAReferra... We had a task force exam this issue.
Jason August 11th, 2008 11:45:00 AM
Thanks, Jason, for your vast stores of knowledge on AAHA.
For those who want to look at these guidelines, click on Jason's link, go to the resources tab, select references and under AAHA Guidelines you'll find these referral guidelines which you can download as a PDF.
Dr. Patty Khuly August 11th, 2008 03:13:00 PM
Dr. Khuly, your point about doctors "learning" on their patients is one I have taken to heart. I had a personal experience with a very green GYN eager to remove an ovary for what turned out to be an endometrioma and two second opinions told me it's not necessary. When she was recommending this, I asked her how many oophrectomies she'd done and the answer was shockingly low. She hastened to reassure me that her boss would be watching, but nah, no thanks. Same young girlie got my test results mixed up with someone else. This is at a very established "well respected" practice. I think she just wanted the experience.
Don't be cutting into me to raise your skill level!
I have not had a reason to have my pets subjected to any surgery more complex than dental in the last several years, but I have translated this experience to my pets. I will always make sure that anyone operating on my pets has tons of experience and a clean record.
Stefani August 11th, 2008 04:00:00 PM
Jason, the link does not reflect the information----can you excerpt any of it for us?
Barbara A. Albright/New Hampshire August 11th, 2008 05:58:00 PM
Cancel that, I found it & thank you Jason for providing it. Certainly sheds light on what "should" have happened in my bad referral----Thanks again
Barbara A. Albright/New Hampshire August 11th, 2008 06:18:00 PM
Dr. Khuly,
The case that Stefani was referring to was ours - and that of our beloved Stempy. The thing is....a cystotomy was scheduled and the only thing authorized. She had already performed a cystotomy previously on Stempy. When we went to pick him up - the vet tech greets us by telling us this doctor had never before performed the procedure she performed on Stempy. We were shocked. She claimed to have performed a perineal urethrostomy. However, Stempy remained in tact and no new opening - permanent or temporary - was made. He had a 9 cm incision from his anus to his scrotum. Stempy passed away 3 days later. I firmly believe she did not refer because she did not want another vet to see what she had done (failed to take x-rays, lodged catheter to stone with forceful catheterization0 Click my name to read the full story if you are interested.
Greg August 11th, 2008 08:11:00 PM
Dolittler seems to be a magnet for stories like yours, Greg. Lots of readers here have had experiences like this. Here's hoping posts like this and stories like yours convince people that veterinary medicine is no different from human medicine. Doctors of all stripes are just people. Most people are mediocre. We're all fallible. And everyone needs to learn how to advocate for their pets before and after they're gone. Best of luck to you.
Dr. Patty Khuly August 12th, 2008 08:32:00 AM
Levels of negligence are tolerated in veterinary medicine that would result in massive lawsuits or huge settlements in human medicine.
Notwithstanding human fallibility and the need to advocate for our pets, these facts do NOT shift responsibility for botched surgeries, failure to refer, incompetence, negligence or worse from the veterinarian to the pet owner.
While it may not be legally required for a human doctor to disclose that he has never done a particular type of surgery before, or has minimal experience, the medical institution in which most doctors operate would not allow a surgeon to do a first time surgery alone or as a lead on a surgical team, I bet. And if a surgeon did do a procedure, without disclosing, that he'd never done it before and serious injury resulted, or death, I'd be willing to bet he'd be quick to settle rather than see that case make it to court.
Not so in vet med, since there really is no viable legal remedy to such behavior and thus no deterrant.
I do believe that while the law may not require a vet to disclose that he or she has never done a particular procedure that he proposes to do on your pet, the fault is nonetheless his when his inexperience leads to injury or death through botched surgery -- whether the owner ASKED or not if he'd done this procedure before.
Just because the sad, harsh, unfortunate reality is that we need to take NOTHING for granted with health professionals doesn't mean that the attitude of health professions toward patients should be "buyer beware."
The doc is still responsible for making sure he practices within his skill level. In no way does an owners failure to ask:
"How much training does this technician have giving insulin?"
or
"How many times have you done this surgery?"
absolve a negligent practitioner.
We should not be punished for our trust.
Stefani August 12th, 2008 12:56:00 PM
Dr. Khuly,
The procedure she performed was unauthorized! At NO TIME did we EVER authorize her to do anything other than a cystotomy. While we were naive enough to blindly trust this "veterinarian," no amount of advocating can prevent a veterinarian from performing unauthorized procedures when you are not around if they so choose. She had lodged the catheter to the stone 3 days before the surgery. Nothing had changed. When she discovered what she had done, she should have referred. This just scratches the surface of her negligence. Read "What happened to Stempy?" on his main page.
So, Dr. Khuly, are you saying that pet owners must remain present, IN THE ROOM, when surgical procedures are performed? How else would we be able to advocate for our pet? That's a far cry from human medicine, wouldn't you agree? Yes, we learned a painful lesson that you can never blindly trust your veterinarian. Mediocre? If she had been at least mediocre, Stempy would still be alive. Who is supposed to be the trained professional?
Remember, there is little or no recourse when a vet malpractices your pet. Not true in human medicine. On the rare occasions when the vet board actually does dole out punishment, it is woefully inadequate to act as any type of future deterrent. Have you read Stefani's "Bad Vet Daily" blog? If not, I challenge you to do so. I wholeheartedly disagree with your comparison.
Greg August 12th, 2008 04:05:00 PM
Never shift the responsibillity of a fatal outcome to the pet guardian! It's not professional. My pet died 3 days after discharge and the vets involved tried to blame me for his death--how unprofessional!
Fotini September 22nd, 2008 01:22:00 AM
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