Letters to dvm360: Referral scenario draws criticism from specialists

The following letters to the editor were submitted in response to Dr. Marc Rosenberg's August column, "Referral, interrupted: GP faces resistance from oncology specialist."

On behalf of the board-certified specialists at the American College of Veterinary Internal Medicine (ACVIM), I want to express my disappointment in Dr. Marc Rosenberg's August column.

The article presents only one side of the story and doesn't address any of the serious safety issues of chemotherapy exposure in a practice. Oncology specialists are willing and prepared to take on this inherent exposure at their and their staff's risk.

This article is also not indicative of how the majority of board-certified specialists operate. The ACVIM and its members work hard to educate animal owners and primary care veterinarians about the triad of care and the benefit of working with a specialist to provide the best possible care for animals.

ACVIM members are dedicated to this synergistic approach with our primary care colleagues. We'd ask that in the future, your publication focus on promoting this triad of care instead of creating animosity between colleagues.

Zachary Wright, DVM, DACVIM (oncology)

Chair, ACVIM Marketing and Communications Committee

I am a board-certified veterinary oncologist and feel compelled to express my negative opinion of Dr. Rosenberg's article. Its tone suggests that the primary role of a specialist is to provide “support” for a general practitioner's diagnosis, offer diagnostic and treatment recommendations and provide those to the general practitioner openly. This is a completely untrue and unrealistic expectation for individuals such as myself.

I didn't complete a one-year internship and three-year residency program, endure the grueling process of passing board exams and writing an original research paper solely so I could provide verbal treatment recommendations to a colleague who did not endure such training without actively taking part in the care of the pet in question. To suggest that specialists do so is absurd.

I've been in the shoes of “Dr. Folk” too many times to count, and it's an extremely frustrating situation. Not because I'm upset about losing revenue associated with the case, but because I know what a miserable situation it is to attempt to co-manage cancer cases with inexperienced veterinarians who believe they can do my job as well as or better than I do.

When a primary care veterinarian expects me to offer my treatment protocols and essentially walk them through how to manage a cancer case without my having an active role in that pet's care, it is not only illegal but it is not in that animal's best interest. I take major issue with the suggestion that Dr. Folk should have offered to provide his plan to Dr. Canto without question.

For one thing, I would question whether Dr. Canto had sufficient knowledge regarding the safe handling and administration of chemotherapy. These are dangerous drugs that can have serious (even fatal) complications. Does this doctor have specialty-trained technicians with experience administering cytotoxic medications? Does the doctor have the proper biosafety hood required for drawing up drugs in a safe manner and to reduce risk of exposing the staff to toxic vapors? I've seen veterinarians draw up drugs on the same counter where staff eats meals.  

Has Dr. Canto completed three-plus years of specific postgraduate training in medical oncology so she has an adequate understanding of the immense complexities associated with lymphoma diagnosis and treatment? Does she have years of experience treating cases? I do, and I still carry anxiety about whether the diagnosis is correct and my plan is the right one, and I still have trouble with some patients' side effects to drugs.

Veterinarians consistently say that they are undervalued, disrespected and underpaid compared to our human counterparts. Yet articles such as Dr. Rosenberg's sustain the notion of how veterinary medicine lags behind human medicine. If Dr. Rosenberg were to be diagnosed with cancer by his primary care physician, I doubt he would consult with an oncologist, take the information garnered from that appointment and return to his primary care physician for care.

Veterinary specialists exist not because we “need revenue just like any other business,” as Dr. Rosenberg suggests, but because we fundamentally believe that we can offer a standard of care for companion animals on par with human medicine.

I am disappointed that dvm360 published Dr. Rosenberg's article without offering an alternative opinion by a board-certified veterinary oncologist.  

The most disgraceful part of Dr. Rosenberg's article is this statement: “It's tempting for a specialist to encourage a referred client to continue treatment at his or her own facility. This temptation must be resisted. It's unethical and, from a practical point of view, will discourage future referrals if the generalist feels he or she may lose a client.”

It is not “tempting” for me to encourage a referred client to continue treatment at my hospital-it is in that pet's best interest that a board-certified veterinary oncologist treat its cancer. What is unethical is a primary care veterinarian being so worried about losing a client that she feels the need to engage in activities that put her own health-and the health of her staff-at risk.

Joanne Intile, DVM, DACVIM (oncology)

Riverhead, New York 

As a surgical specialist (not an oncologist), I am amazed and frankly disgusted that Dr. Rosenberg's August column was printed and find a complete lack of understanding regarding the issues at hand. This article is not an accurate representation of specialty medicine.

Dr. Rosenberg's comments at the end of the article suggest that the only reason specialists in this type of scenario respond this way is for financial reasons-an incorrect assessment. Dr. Folk is absolutely correct in his response to deny the request for doses and protocol. Protocols are available in any textbook, and Dr. Canto can find them anywhere. They are not hidden.  

Dr. Folk gave his recommendations for treatment. He is a boarded oncologist. If it were so easy, why does Dr. Canto need Dr. Folk's opinion in the first place? Medicine is not cookbook. Each exam, treatment and CBC is used to make the best recommendation for that particular patient. The value of a specialist is not in the doses of chemotherapy. The value comes in his or her experience tailoring the particular treatment to a specific patient.

Despite what Dr. Rosenberg may believe, specialists are not making recommendations for money. They are making recommendations in the best interest of the patient. And what is in the best interest of the patient is that the case be managed by someone with insight and experience regarding the subject at hand.  

Marc Hirshenson, DVM, DACVS

Huntington, New York

Regarding Dr. Rosenberg's August column: One thing I would like to bring to light is a new law coming down the pipeline in the state of Washington that will greatly impact the private practitioner's ability to perform chemotherapy in general practice. 

The law will require facilities with staff who handle chemotherapy agents to have a self-standing hood that vents to the outside wall, a separate area for chemotherapy administration, a separate area for a chemotherapy mixing station and a closed administration system, along with many other “rules” that we oncologists in Washington will have to abide by. 

Legislators are trying to make it safer for all of us handling chemotherapy on both the human and veterinary side. Pharmacies in human hospitals here are in an uproar because many of them have to change the configuration of where the pharmacy is in relation to the hospital to accommodate for the venting of the hood!  

I envision this will trickle down to the veterinarians who treat an occasional lymphoma-they will be fined for practicing with chemotherapy without the proper setup. Having just set up my own oncology practice, I can tell you the investment in the hood alone with installation is $12,000. Not many private practices will adhere to this rule and make the changes to their practice. My understanding is this law will likely be adopted by other states in the future.  

Just because you can work with chemotherapy doesn't mean you should. There are safety concerns involved for staff and clients. Referral for safety considerations should be considered.

Chelsea Tripp, DVM, MS, DACVIM (oncology)

Seattle, Washington