For Veterinarians Overview
The Role of Referring Veterinarians in Providing Optimal Patient Care
David Bruyette, DVM, DACVIM (Internal Medicine)
Medical Director
VCA West Los Angeles Animal Hospital
Veterinary medicine has become increasingly more specialized in the last decade. The number of residency training programs and diplomats in a variety of sub-specialties (internal medicine, cardiology, oncology, neurology, surgery, radiology, radiation oncology, dermatology, ophthalmology and behavior) is continuing to expand. The growing number of diplomats of the American College of Veterinary Practitioners also points to the emphasis on continued education and specialization within the profession. Internship and residency programs are becoming increasingly more common outside of academia and the emergence of large well-equipped multi-specialty hospitals are rivaling and in some cases surpassing the talent and equipment available at universities. These are trends that are likely to continue as both the profession and the pet owner seek specialists and specialty care. How then can we assure that clients and their pets are best served with a system utilizing general practitioners, practicing specialists and academicians?
When should a referral be considered?
Referral should be considered in several circumstances. Certainly, at any time a case or potential procedure appears to be either beyond the scope or capabilities (training or equipment) of the referring veterinarian. The initial evaluation and work-up of the patient may not have led to a clear diagnosis and consultation may be considered prior to embarking on additional testing or empiric therapy. Alternatively, a diagnosis may have been reached (e.g.lymphoma) and referral is being considered for treatment. This initial consultation may take the form of a telephone call or e-mail to a local specialist or to a specialist outside of the area with a particular interest or expertise in a given field. The practitioner may elect to use the services of a telemedicine or teleradiology company or a service such as VIN (Veterinary Information Network) to gain further insight into a particular case or pending procedure. After such initial consultation the practitioner may elect to continue care with the added input from specialists, or they may elect to transfer the patient for additional testing or therapy.
Secondly, patients may be referred when the client has expressed the desire for referral to a specialist. This may occur as the result of a perceived need for specialty care, the past experience of the client, their friends or family with similar situations, or the desire for a second opinion. In fact, it is becoming increasingly more common for clients to solicit multiple opinions from several specialists prior to making a decision. This is particularly true with specialties such as surgery and oncology where multiple treatment options may exist for a given diagnosis.
Thirdly, referral may be sought or requested when the clinical course of the patient has been unexpected or further care of the patient requires more intensive monitoring and treatment than initially expected. At this time emotions may be high as the patients condition may and often times is critical and finances may need to be carefully re-evaluated.
How should a patient be referred?
Ideally, the general practitioner and specialist will have communicated prior to the client arriving at the specialty center. This may not always be possible given scheduling conflicts, owner availability, and the urgency required. If prior communication is not possible, it is very important that the referring veterinarian (RDVM) provide a detailed history (ideally a summary of the case rather than the entire patient record), copies of the laboratory work, and any imaging studies that may have been performed. The specialist may contact the RDVM to help with any unanswered questions shortly after the patient has been admitted. The RDVM will then be contacted and updated as needed during hospitalization and then contacted again at time of patient discharge or resolution of the case. It is imperative that the specialist provide relevant timely information to the RDVM. This will ensure proper follow-up of the patient and provide the RDVM with information that will be incorporated into the patient's medical record. A referral letter summarizing the diagnosis, treatment and follow-up information should be sent in a timely fashion along with any pertinent laboratory and imaging results. This information should be sufficient to inform the RDVM as to what was done and what needs to be done to ensure continuity of patient care.
As part of the referral process it will also be important to provide the client with accurate financial information. The costs for specialty care will be in addition to and likely much higher than those associated with general medical and surgical care. It is not uncommon for clients to spend $ 2,000 to $ 5,000 (and in some cases much higher amounts) for specialty care. We have seen a large increase in the number of clients with pet insurance and in turn an increase in the coverage amounts and types of conditions included in insurance policies. This will continue to grow as more consumers become aware of the advantages afforded by insurance. Written estimates are provided prior to starting treatment or diagnostics. In general 50-75% of the estimate is required as an initial deposit with the balance due at the time of patient discharge. Multiple payment options may be available to help clients who are unable to pay their balance in full at the time of discharge (e.g. CareCredit). Clients with such financial concerns should bring those to the attention of the specialist at the time of initial consultation. It also can be a great help for the specialist and the RDVM to have discussed estimates prior to referral to help avoid needless visits especially when financial concerns may preclude specialty services.
What are common concerns regarding referral to a specialist?
At times concerns may arise regarding referring patients to a specialist for additional care. A common concern is that the client may get the impression that the RDVM has done something wrong or is not as competent as the specialist by the very nature of the referral. We can help to allay such concerns by emphasizing a team approach to patient care such as is commonly done in human medicine. A family practitioner or pediatrician refers you to an internist who then may in turn refer you to a surgeon or oncologist. Our clients and our profession are increasingly coming to the realization that veterinarians cannot be equally proficient in all areas and it is to everyone's advantage that specialization exists.
In addition it is very important that we take care not to say or infer anything that might be construed by the pet owner as being derogatory or negative with regard to the care their pet received at the hands of the RDVM. As specialists we are often not privy to all the conversations that existed between the client and the RDVM and such conversations may be open to a variety of interpretations especially when viewed retrospectively. We all have had clients who, after time for reflection, have made a 180 degree change in their thoughts regarding additional testing and treatments. Such changes in attitude are not uncommon during a pet's illness and a client may elect to choose one course of action over another after consultation with the specialist even though those same options were offered earlier by the RDVM. If a specialist has a concern about the care provided by the RDVM those concerns should be voiced to the RDVM for further discussion and not voiced to the client.
Another concern that may limit referral is the perception that a pet and a client may be lost to the referring hospital after the case has been closed. The specialist is not there to 'steal' clients away from RDVM's. In fact, RDVM's are our clients and as such we need to meet their needs and address their concerns. Many referral hospitals are intentionally setup in such a way that ongoing general care is not possible (no elective procedures, vaccinations, over the counter medications, non-prescription diets, etc). Those referral institutions that have both a general and a referral base need to take special care to ensure that follow-up and ongoing general care is transferred back to the RDVM as appropriate.
Role of Academicians
As specialty clinics continuing to expand throughout the country both in number and in breadth what role does the university teaching hospital play in patient care? In the past virtually all specialists were found in academic settings. This is no longer the case and caseloads at some university teaching hospitals have been affected by the presence of private specialty clinics, which emphasize patient care and promote timely referral from RDVM's. The role now of the university teaching hospitals will be to serve as the leader in clinical and basic science research. Less emphasize will be placed on clinical cases and clinical teaching responsibilities (this may more effectively be accomplished in cooperation with private specialty hospitals) and more emphasis placed on allowing faculty time to develop research programs. Such an approach will allow for more rapid development of new ideas that can be transferred quickly into the clinical setting. Together with specialists in private practice and general practitioners such an approach will benefit the continued growth of the profession and more effectively meet the health care needs of pets and the wishes of their owners.
Summary
The role of specialists within the profession will continue to expand in the 21st century. Pet owners are more educated than ever before and they will continue to seek out those services that offer their pet the best health care possible. We will continue to work as a profession to make clients aware of these services and promote clear communication between the specialist and the RDVM. In such a scenario all parties win.
