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.