From Islands to Networks: The future of veterinary practice (Supported by Nestlé Purina, Pfizer Animal Health, and the Veterinary Specialty Practice Alliance)

A change once viewed with suspicion, the rise of referral practices and the creation of veterinary communities is rapidly gaining acceptance. Craig Woloshyn, DVM, owner of Sun Dog Veterinary Consulting, thinks the referral practice "is probably the best thing to happen to our profession in the past 15 years." Link Welborn, DVM, DABVP, who worked on the American Animal Hospital Association (AAHA) accredited referral practice task force and served as AAHA president from 2003 to 2004, thinks both primary care veterinarians and specialists genuinely appreciate the medical benefits of joining forces.

The road to transition has not always been smooth

Neil Shaw, DVM, DACVIM, is Dr. Welborn's referral partner in Tampa, Fla. Dr. Shaw is the founder of Florida Veterinary Specialists, a referral practice with 50 veterinarians. They work together often, and both extol the benefits of their collaboration. But that doesn't mean everyone sees the rise of referral practices the same as these two colleagues.

"The role of the traditional practice is changing dramatically," Dr. Shaw says. "There has been, in recent years, growth in specialty and referral practices. Some veterinarians, especially in high-quality primary care practices, aren't sure if this is good or bad for the profession."

Dr. Shaw says those who might be reluctant to refer are "denying the obvious." The body of veterinary knowledge is ever expanding, and referral practices have become an extension of the primary care hospital. As Dr. Woloshyn puts it, "Everybody wins." By practicing in partnership, primary care veterinarians and specialists provide the best care possible for a pet—enabling the pet to live a longer and healthier life. And a longer life span translates into several things: it increases the owner-primary care practitioner bond, nurtures the owner-pet bond, and creates a longer patient-practitioner relationship (which results in more income for the primary care practice).

Referral practices were unheard of 25 years ago. In those days, most specialists practiced in academia within university veterinary hospitals. Later, some specialists emerged in large primary care practices in mostly urban communities. While many veterinarians sent difficult cases to the university, sending clients to another for-profit practice across the street ran against the grain.

Specialty and referral practices emerged for many reasons. Some say specialists tired of practicing in the academic atmosphere. In recent years, veterinary care has followed in the footsteps of human health care—changing from a one-doctor-fits-all mode to that of a primary care physician providing overall care and referring patients to specialists when appropriate. "To a large degree," Dr. Welborn says, "public awareness that different specialties are available made demand for this change in veterinary practice necessary." Increased awareness (via the Internet age), is only accelerating that change.

The professional relationship between primary care practitioners and specialists is still in transition, Dr. Welborn says. That's where the 10-person AAHA task force came in.

"Both primary care veterinarians and specialists in local communities have concerns, and sometimes the two parties are not open to dialogue. The task force filled the void when it developed the guidelines. In the end, it's all about communication among the parties involved—primary care veterinarians, specialists, their respective practices, and their mutual clients."

The guidelines adopted by AAHA in March 2007 address key points:

• Guidelines on when to refer

• A call for mutual respect between primary care veterinarians and specialists

• Discussion on duplication of diagnostic tests and maintaining good communication.

However, the thorny issue of returning clients to the original practitioner still concerns primary care veterinarians.

Increasingly, Dr. Shaw says, the issue is rendered moot by the organization of specialty practices as freestanding entities. In his experience, referral practices work best this way because it's difficult for a doctor to effectively be in a room with a client as a specialist, then walk down the hall into another room to treat long-term clients as the primary care veterinarian. Playing a dual role doesn't always mesh easily and efficiently. But both the primary care practitioner and the specialist can develop practices that are stronger, more viable, and consequently, offer the best health care for pets—if they concentrate on what they do best.

Where one plus one may equal more than two

Dr. Welborn operates four hospitals in Tampa with his partner Timothy P. Lassett, DVM, DABVP: Pebble Creek Animal and Bird Hospital, Temple Terrace Animal and Bird Hospital, North Bay Animal and Bird Hospital, and The Cat Doctors. Both doctors interact closely with Dr. Shaw's referral practice, even sharing interns in three-week rotations to give them exposure to both high-quality primary care and specialty practices.

Dr. Welborn's strategy for making the most of the relationship with Dr. Shaw's practice has been to invite specialists from the Florida Veterinary Specialists facility to eat lunch with his staff members once a month. An internal medicine specialist came to lunch in March 2007 to talk about what the specialists could do to drive his practice. A cardiologist visited in April. Welborn said the meetings were beneficial for both practices.

Extending your practice adds to your repertoire

"The decision of when to refer is easy," Welborn says. "If you don't provide the service, you refer. If you don't have the equipment or expertise, you refer. A nasty fracture comes in and needs a plate. You automatically refer to a specialty practice.

"In an internal medicine case, you've moved fairly far into the process of working up a patient. You refer as opposed to telling the client, 'Sorry, there's nothing we can do.' In some areas, the more you know, the more likely you recognize the need for another line of diagnostic testing or treatment."

Dr. Woloshyn agrees. "You can," he says, "fix things you could never fix before." Smart practitioners, he says, recognize how referring clients to specialists expands the scope of their own practices. The partnership provides an extension of care—a definite benefit for the pet, the owner, and both veterinary clinics involved.

"It allows the primary care veterinarian to give university-level care without going back to school and without an investment in tremendous amounts of equipment," he says. "We can offer treatments we could never offer clients before." OK, but will it benefit you financially?

Is referring profitable?

All that great medicine is well and good, but does referring clients positively impact the primary care veterinarian's bottom line? Yes it does, Dr. Woloshyn argues, and for the best of reasons.

"What happens is that today we can do something about cases we could not impact before," he says. "That helps increase the human-animal bond. And, when we increase the human-animal bond, we benefit directly."

In addition, the primary care veterinarian provides more care for the pet after it is treated at the specialty practice. Not only are the clients more deeply bonded to a pet that has been saved, they are more clearly bonded to the primary care veterinarian who obtained the most sophisticated care for their companion.

Don't underestimate a client's willingness to pay

One issue some referred clients will face is sticker shock. The best way to approach this issue may be to make the client aware that specialty care might cost more than the what they might be used to. It's the same principle as it often is in human medicine. However, the specialist can often zero in on the specific tests needed for a faster diagnosis and treatment—which could actually save the client money in the long run.

A common mistake is the assumption that a client might not be willing to pay for specialty care. Pets are often considered a member of the client's family, and most owners are willing to pay in order to save their pets or extend their quality of life.

In the end, everyone can benefit from the collaborative circle that has developed within the world of veterinary medicine. Those who benefit the most are the pets, which have the best of both worlds: regular and preventive care from their primary care veterinarian, and specialized care—when there is a need.