The age of specialization

Veterinary school: fall semester, 1969

J.D. Mason moved quickly down the hall, an armload of books on his hip. The sound of his classmates' voices grew louder as he neared the student recreation room. He entered and soon realized that this was more than the usual buzz.

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Four of his classmates sat around a small table. Usually they played hearts with an old deck of cards (a select few knew that the queen of spades was nicked ever so imperceptibly at one corner). But today the cards were still on an old lab counter donated from the microbiology room. The four were talking excitedly.

"Hey, J.D. Have you heard the news?" asked Tom Franklin.

"Say what?" J.D. replied, dropping his books on the counter.

"Mike Johnson is leaving the small-animal clinic to start his own practice in Chicago."

J.D. was stunned. Dr. Johnson would have been the school's junior surgery instructor this semester. Everyone considered him the best surgeon on staff. He was the type of teacher that students love — big into the practical approach to veterinary medicine and surgery. He spent five years at the Animal Medical Center in New York before coming to the university.

"Hey, J.D., that leaves only Dr. Morris and Stanley Kramer in large animal to teach us this year," piped Chuck Nelson, a short redhead from southern Indiana.

"Mike was gonna let me scrub in this year on some of his back surgeries," lamented Peter Wise.

"Yeah, it's a pity," said Randy Fox. "Mike would take the time to explain surgical stuff to us even when we were freshman and we stunk with formaldehyde from anatomy class."

J.D. looked down at his friends. They were all committed to doing a lot of surgery when they got out of school. Most wanted to work a couple of years doing mostly surgery and then start a practice or begin a surgical residency somewhere. The Holy Grail was finally to work in the clinics of a vet school. All five were considered the sawbones by the rest of the class of 1970.

Other classmates had started showing preferences as well. Some wanted to do cardiology or dermatology. They were all looking out to a world full of sick animals and bright careers.

As for Mike Johnson, this was an aberration. The pinnacle for a veterinary surgeon was to work on the clinical staff at a prestigious university and to be on the clinical staff — both teaching and doing all the referral surgeries sent in from veterinarians from all over the country. This is just the way things were.

The group consensus was this: What was Mike Johnson thinking? Leaving the university would be a big step down. He certainly couldn't compete for the best surgeries, because local veterinarians would always refer the most involved and most interesting cases to the vet schools. He would be marginalized. Mike would likely be back here with the "big boys" after he finds out that private practice without spays and rabies shots just won't work.

As it turned out, Dr. Mike Johnson did just fine.

September 1971

Rochester (Ohio) Animal Hospital

J.D. Mason's right index finger was red beneath his surgical glove.

"Drat, there must be another hole," he thought.

"Mary, bring me another pair of gloves, please."

This was his third pair of gloves as he labored to repair the left tibia and metatarsal area of a large Doberman. He had been in surgery for about two hours and was finally satisfied with the combination of pins, wires and plates he had used to complete the fracture fixation.

J.D. just returned from his first ASIF meeting in Europe and was trying out some techniques on this patient that he never tried before. Since graduating from veterinary school last year, he had done numerous difficult, yet satisfying, procedures. His boss, Gerald Simmons, was more than glad to let him try. Gerry was a self-proclaimed klutz in surgery and before J.D. arrived he referred all the bone surgeries down the street to Dr. John Holmes, who would do some of the more "oddball" surgeries for colleagues in the area.

Gerry gave J.D. an equipment budget and free rein. J.D. had paid his own way to the overseas ASIF meeting. He would even pay off his student loan in another two years. Life was good.

J.D. loved his job and, if possible, would do surgeries all day long. With the exception of a few "neuro" cases, the prospect of referring surgeries was mostly unthinkable. Besides, J.D. knew everyone at the vet school and would occasionally accompany the pet to the university and sit in on a given surgery to pick up some new techniques.

Within a few years Dr. Simmons sold J.D. the practice and J.D. was doing most of the complex surgeries for a lot of the practices in his area. Gerry was happy to stay on part time for several more years.

Spring 1982

Rochester (Ohio) Animal Hospital

J.D. looked at the new phone book, wincing and twisting his neck. His face suddenly seemed more weathered and tired as he flipped the pages in disgust.

"What is going on here?" he complained to Gerry, who by now was down to one day per week.

"You couldn't even put a bold listing in the Yellow Pages when I got out," Gerry sputtered through a partially eaten doughnut.

"Yeah, but these guys are advertising that they 'specialize' in orthopedics," lamented J.D. "None of them probably knows what a k-wire is."

"I dunno. You can't do a thing about it," Gerry said between a final sugar-cleaning of his index and thumb.

Gerry went on, "You got nothin' to worry about — you have been doing surgeries all these years. Next to the university, you are it. I would quit worrying."

J.D. wasn't so sure. The next day he called his old classmate, Tom Franklin, who had changed his mind about surgery as a fourth-year student and got really interested in cardiology. He stayed, did an internship and was now in a large practice in the Cleveland area. J.D was in no mood for idle chit-chat.

"Hey, Tom, how ya doing? Say, what is going on in your area? We have veterinarians opening up all over our town. Some are doing specialty work and haven't really had much experience."

"You ought to be up here," Tom replied. "Several practitioners combined their practices last year within a few blocks of us. They're hiring all kinds of new grads and even lured a specialist away from the university. It's just ridiculous. Until then, I got all the interesting cases in this part of Cleveland. There are vets setting up on every corner. They all seem to be go-getters. It beats me how we can all survive."

J.D. twisted his face once more. "The golden days of small-animal practice are finally over."

In spite of the competition, J.D. continued with a large surgical load, albeit one that was slowly diminishing.

October 2002

Rochester (Ohio) Animal Hospital

Monday a.m.: Dr. Sarah Jennings was the newest recruit and had been on board almost a year now. She loved her job but was caught between a rock and hard place. She had done well in surgery her last year of veterinary school year and even considered a residency. But her final decision was to go back to her home area, try to gain some experience and develop her communication skills with clients. She really wanted to be a generalist and do both surgery and medicine. Besides, she had been taught to refer much of what would have been "bread-and-butter" cases just 10 years ago in many private practices.

When she was hired, she knew that J.D. Mason had done a lot of surgery over his career, but she had no idea the extent of his experience.

She was glad to pass on all but the simplest surgeries. But now she was uncomfortable with what had transpired last week. J.D. had asked her to assist in a difficult procedure.

"Sarah, I want you to take over and let me assist you," he said after Sarah was already scrubbed and gowned.

Sarah started to perspire visibly and her glasses fogged. This was not comfortable.

"Sarah, I need you to start taking a very active role in surgery. I think you would do very well doing a lot of the big surgeries that I do now."

A knot formed in her stomach. Under her mask, Sarah bit her tongue to fend off a brief dizzy feeling.

While this was a wonderful compliment, her discomfort came from the realization that many of these surgeries could (or should) be referred to the downtown hospital for the best potential outcome for the patient. How could she tell her boss?

Although J.D. had a lot of equipment, the downtown specialists were open 24/7 and were all board certified. She had been taught that referral is almost mandatory if specialists are close at hand.

Sarah finished the surgery with much input from J.D., but her inner conflict remained.

J.D knew something was wrong but couldn't put his finger on it.

Tuesday a.m.: J.D.'s feet were atop a pile of journals in the center of his desk.

"Tom, I'll turn 60 next year and really need to look at selling all or part of this practice to someone that likes to do surgery."

J.D. explained this as he slumped deeply into an overburdened office chair. He needed some answers.

Tom Franklin listened at the other end.

"I have had several vets over the years come in, but I never let them do much surgery. I really wanted to do most of it. Anyway, I never did get anybody with the passion you need to be really good," J.D. went on.

"I called the university last year. The best surgical student was a young lady named Sarah Jennings. It turns out she's from this area, and I was lucky enough to hire her. She's been with us a year and is doing great."

J.D. looked at the door to his office. It was open. He got up to close and lock it. While doing so, he pulled the cord enough that the phone fell on the floor with a horrid jangle sound.

"Tom ... you there?" J.D. hollered. (Tom knew what had happened)."

"Yes, J.D.," Tom said slowly, "Do your surgical clients know that you have always been a big klutz?" Tom roared.

J.D ignored the put-down and sat back down. His mood changed.

"I am confused," he said.

"Sarah acts as though she doesn't really want to get involved in our more difficult surgeries."

Tom was silent for a moment:

"J.D, the 21st century started almost three years ago."

David Lane

Dr. Lane is a graduate of the University of Illinois. He owns and manages two practices in southern Illinois. Dr. Lane completed a master's degree in agricultural economics in 1996. He is a speaker and author of numerous practice management articles. Dr. Lane also offers a broad range of consulting services and can be reached at david.lane@mchsi.com