Ways to close the care gap between general practitioners and specialists

By R. Randy Basinger, DVM, ACVS

The veterinary care gap exists because a segment of pet owners is committed to giving their animals the "best," but is unable to pay the cost of treatment by a specialist. However, when they request their family veterinarian's help, they find their family veterinarian does not have the training, equipment, or time to handle the problem.

This care gap may be more pronounced with surgical problems, though it can occur in any area where special training or equipment are needed to deliver the care. This gap is a function of advances in care that require specialized equipment or training, and of the "referral first" paradigm taught at many teaching hospitals. The current shortage of veterinarians exacerbates the problem. It is becoming even more noticeable as the older group of general practice veterinarians leaves the workforce, who were trained and encouraged to do some of these mid-level surgical procedures while in veterinary school. As this generation of veterinarians retires, those remaining at the practice may not have learned these procedures under a mentorship model, much less in a formal procedure-specific format taught by educators current in the newest techniques. This was not always the case—prior generations of veterinarians were taught and encouraged to handle the most common surgical conditions, perhaps because fewer referral options were available.

Specialists are abundant, but expensive

It is certainly appropriate to offer and recommend referral to a specialist when appropriate, and clients can confidently expect a high standard of care should they accept the referral. The cost of delivering that level of care is just beyond the financial reach of many pet owners. In no way does that disparage the value of the services specialists provide for the increased cost; it is just a limiting factor for many clients.

Referral options were also quite limited in the past, and clients often had to travel long distances to access them. Now, there are a few places very far from a specialty hospital, and mobile specialists in multiple disciplines are becoming increasingly common, where pet owners can see a specialist at their home hospital. So, typically, the cost of care rather than access to care becomes a hurdle.

Veterinary schools are having difficulty training new veterinary students' competency in even basic surgical procedures. Veterinary teaching hospitals often manage surgical caseloads that may not provide veterinary students with a strong foundation in treating common surgical diseases they will encounter in practice. Many of these teaching hospitals are really becoming tertiary care facilities, where only the most serious and unusual problems are treated.

Consequently, exposure to mid-level surgical problems and procedures is less common, and referring surgical cases to specialists is emphasized. As teaching hospitals also train interns and residents, sometimes the veterinary student is last in line for hands-on training.

Finally, the sheer volume of material students is now required to learn provides little room for any one discipline to be explored thoroughly. Several recent publications have shown many new graduates and their employers are not confident the new graduate can perform basic procedures such as an ovariohysterectomy independently, let alone cystotomy, enterectomy, and other basic or mid-level elective procedures.^1-3

Real-life scenarios Let's look at some patient cases that illustrate the veterinary care dilemma: A six-month-old Yorkie was stepped on by the owner and sustained a midshaft, interdigitating oblique humeral fracture (Figures 1-4). A referral was recommended, but when the owner went for a referral and was given a $6,000 estimate for plate fixation, she went back to her family practice for amputation. The veterinarian suspected there was another option and employed a simple stack-pinning procedure to manage the fracture. Is there anyone in your practice who would be able to pin this fracture? You are doing a dental procedure and creating a simple unilateral mandible fracture through an alveolus (Figures 5 and 6). Do you call the owner and advise them that it happened and refer to a specialty practice? Or do you call the owner and offer to place a couple of wires to stabilize the fracture before you wake the patient up? Are you willing and equipped to handle this scenario? You explore the abdomen because you suspect a foreign body, but find there is a liver mass or a mucocele. Are you able to biopsy the liver or remove the gallbladder?

New veterinarians learn from mentors

Most new veterinarians advance their skills in a mentorship model at their entry practice. If the mentor is current with the latest techniques and the practice has the equipment needed to manage the problem, this can be a good strategy for new veterinarians to build their skills, procedure repertoire, and confidence. This reinforces the need for more experienced veterinarians to mentor new veterinarians with patience and adherence to best practices.

So, what are some solutions to this dilemma?

More clients taking advantage of pet insurance may ease the financial burden for advanced care. Access to payment plans may also help. Some veterinary schools are embracing the "spectrum of care educational paradigm," where the emphasis is on providing clients with a range of options, including the "standard of care," as well as second- and third-best options for treatment.

The general practitioner will play the primary role in some of the treatment options. A central pillar of this spectrum of care philosophy is the presence of veterinarians willing and able to deliver care at all levels of the spectrum. Consequently, we need to increase the number of general practice veterinarians able to handle these mid-level surgical procedures.

There are currently some good educational opportunities at state and national meetings. Several equipment companies provide excellent CE at their facilities or at other CE meetings. These educational opportunities should be expanded to serve more veterinarians and cover a broader range of procedures. Practice owners will need to encourage their staff veterinarians to take advantage of these opportunities by providing stipends and support.

When general practice veterinarians are managing these mid-level procedures, communication and mutual understanding are key:

• The general practice veterinarian must educate and document with the pet owner information about their level of experience and any limitations the practice may have, such as a lack of 24-hour monitoring. Obtaining and documenting informed consent protects the veterinarian and manages the client's expectations.
• Should a specialist become involved at some point, maintaining understanding and acceptance of the client's choices and the general practitioner's efforts is important to ensure good relations between all caregivers.

For the sake of our patients, let's continue working to fill these care delivery gaps. That's why we became veterinarians in the first place—to help animals and the people who love them.

Randy Basinger, DVM, ACVS, has published five textbook chapters and 14 scientific articles and is a frequent lecturer at the local, state, national, and international levels. He is the former chair of the ACVS Foundation and the former president of the Veterinary Orthopedic Society.

References

1. Frequency of use and proficiency in performance of surgical skills expected
   of entry-level practitioners by general practitioners. JAVMA, Vol 240, No. 11,
   June 1, 2012 pp.1345-1354
2. Stakeholder expectations regarding the ability of new veterinary graduates to perform various diagnostic and surgical procedures. JAVMA, Vol 251. No. 2, July 15, 2017 pp. 172-184
3. Evaluation of the expectations, learning and competencies of surgical skills by undergraduate veterinary students performing canine ovariohysterectomies JSAP, Volume 52, No. 11, November 2011 pp.587-594