GettyImages/VM Twenty-five years ago, I left an otherwise satisfying, highly paid relief position at a local practice because they refused to let me refer patients to specialists (“No patient leaves the building unless there’s absolutely no other option”). Instead, the owner would source nonboarded “surgeons” for the orthopedic surgeries and make do with our GP skills for all the rest. I should have left as soon as it became clear that the unofficial policy was affecting patient care. To my shame, it was only after a few less-than-stellar surgical performances (including the nail in the coffin: a hemilaminectomy undertaken without imaging) that I tendered my resignation. By today’s standards, we would find this once-popular policy repugnant. “What do you mean we can’t send a patient to a boarded surgeon for a TPLO? A critical case to a secondary care facility for after-hours care?” It was infuriating! On the plus side, I had learned a lot more about soft tissue surgery and critical care than I bargained for. Unfortunately, my patients paid a high price for their doctor’s inexperience and what I perceived as the practice’s avarice. Things were different before the new millennium. Back then, a mere handful of specialty practices serviced our major metropolitan area. It was easier to get away with an in-house-only, revenue-building strategy. However, now that ERs and specialty practices crowd the suburban map like spots on a Dalmatian, the landscape couldn’t be more amenable to advanced care alternatives. In fact, we risk lawsuits and license complaints when we fail to refer. Which is as it should be if we are trying to ensure patients aren’t ensnared by a system incentivized to offer a limited range of options. Today we seem to be witnessing the reverse trend. Not only are younger veterinarians more willing to refer than ever before, but they also actually appear to prefer it. Despite the prevalence of production-based compensation and bonus pay structures designed to pay them more for better workups and bigger bills, they are finding it preferable to ship than to keep. Interestingly, this is true even when they should be more than capable of exceeding the minimum standard of care by keeping the patient in-house. In fact, it sometimes remains true even when they know the client can’t afford advanced care. Why the reverse trend? I have a few ideas as to why this may be the case. Here are some of the possibilities: 1) Many of our old-school, do-it-all docs retired right around the pandemic When clients couldn’t afford specialists, these vets were willing and able to take on cases and procedures young veterinarians are now taught to studiously avoid (high complication risks, better off with specialists, etc.). Now that no one is mentoring younger vets to engage with these patients, they’re all being referred, regardless of a client’s ability to pay. 2) Sometimes it’s more expedient to refer When you’ve got a waiting room full of impatient faces, it’s harder to justify spending the time certain cases require. Plus, it’s easier to see a lot more easy cases than one big one. The truth is general practices need to see both in order to survive. We can’t make all our income solely on volume. We’d never pay for in-house labs, radiology equipment, and surgical infrastructure if we didn’t tackle some of the bigger cases, too. 3) Skill insecurity is a huge factor Younger veterinarians—especially the freshly minted—may tend to fear more complex cases, bigger surgeries, and non-routine procedures in general. It’s easier to refer than to learn something new. Plus, if you’re ready to refer these cases when a more seasoned veterinarian isn’t around (say, lunchtime), you start to think it’s OK to refer all of them all of the time. Indeed, that’s why large dog spays are increasingly referred to surgeons. Why would I risk a patient’s life when a specialist would do it better? 4) Mentorship is the through-line for the above three explanations When mentorship is inadequate, the fear of taking on tough cases can take a while to shed. This also helps explain why so many graduates eschew surgery. Having a mentor walk you through makes all the difference. However, mentorship is hard to come by when: a) corporate practices think they can sub-in some online mentorship tools and a few wet labs; b) no one gets compensated for mentorship (in fact, the time invested in another’s progress often detracts from their own compensation), and c) who wants to invest in a newbie who stats say will be gone in a year? 5) It starts in vet school, though Graduates are typically taught by specialists in an ivory tower style of practice. They’re also trained to believe there’s always an ideal way to handle any given type of case. If they don’t have the exact right tools, skills, and budget, they tend to think they’re doing the patient a disservice by treating them at all. 6) They’re also taught to stand their ground If a client can’t afford the basic estimate or is unwilling to elect diagnostics, it’s best we send them on their way. “I refuse to offer any kind of treatment if they can’t (or won’t) pay for diagnostics. Let the ER try. Can’t wait for them to see that estimate.” Younger docs often take a firm, unnecessary stand on these cases. Referring away is an extension of this my-way-or-the-highway line of thinking (It’s also how ear infections and UTIs leave clinics untreated.). 7) Here’s a corollary to standing your ground: “If a client can’t pay, then they shouldn’t have pets” I’ve heard this said many ways. “Love is not enough” is another phrase that’s bandied about. It’s easy to make judgments like these when you’re a veterinarian. After a few seasons as a veterinarian, it gets harder to cling to absolutist positions like these. After all, who are we to deny pets to anyone, much less someone who’s asking for your help? 8) End-of-the-road discussions are hard Getting some clients to recognize the need for euthanasia is only doable when a specialist or ER doc says there’s little they can do without a salvageable patient and/or a reasonable budget to work with. Sending a client away can be defensible in these highly charged cases, but shouldn’t we be able to have these tough discussions? After all, we know our clients and our patients. Aren’t we in the best position to be kind, compassionate, and careful in our discussions with them? 9) A legalistic environment makes keeping patients in-house much harder Even when we know we’re doing right by our patients and their people, the perception among veterinarians is that a lawsuit is always just over the horizon. Why take the risk? Has the pendulum swung too far? I do believe it has. Back in my first job (a stint in a small regional ER), I had no access to specialists or critical care centers nearby. My mentor was a phone call away, but I mostly learned from my techs. We made do, and I killed no one (that I can recall). Could I have done better? No doubt. However, I would have learned a lot less if I had been able to punt all the cases I felt unworthy of tackling. Even back then, we were always taught to offer the best medicine available first. The trouble today is our area’s best is almost certainly not what a GP offers on almost anything (beyond wellness medicine). By that measure, each and every non-routine case should be referred to a specialist or critical care facility. Is this where veterinary medicine is headed? I sure hope not. Patty Khuly, VMD, MBA, runs a small animal practice in Miami, Fla., and is available at drpattykhuly.com. Columnist's opinions do not necessarily reflect those of Veterinary Practice News.
