Limited licensure ignites debate

National Report — Some call it evolutionary. Others consider it a mistake. No matter how it's defined, limiting the licenses of veterinarians is stirring national debate, from college classrooms to the American Veterinary Medical Association (AVMA).

On the fence: The idea of limited licensure weighs heavily on Dr. Leon Pielstick. "It breaks my heart, but it's a direction I think we need to go," he says.

The outcome could mean licensure limitations much like those in engineering and human medicine, experts say. Proponents consider narrowing the scope of licensure via species a fix for manpower shortages in food-animal and other deficient sectors by possibly reducing the duration and cost of earning a DVM degree. Critics counter it will erode veterinary medicine's broad education — a professional strength. Yet at the argument's core exists one fundamental question: Has medicine become so complex that students can't graduate within four years and be competent in all species?

It's a polarizing topic dividing DVMs on both sides of the debate with state regulators and national organizations now entering the fray. In 1989, a Pew report titled "Future Directions in Veterinary Medicine" mapped a need for colleges to create "centers of excellence" to facilitate a limited-licensure education system with multiple re-entry points. It also made a startling revelation: Not all veterinary colleges need to teach all species.

The concept was revived with last year's Foresight Report — issued by the Association of American Veterinary Medical Colleges (AAVMC) — which considered implementing species-specific education and licensure restrictions within a decade. While much of the profession clings to the "all creatures great and small" tradition, influential pockets of change supporters are emerging, looking at ways to transform the current education model into one that effectively feeds more than small-animal medicine, but public health, research and starving food-animal sectors. Proponents argue that without limited licensure, veterinary medicine's exploding knowledge base requires additional schooling, which would further tax a student body already drowning in educational debt.

If limited licensure is to succeed, it must be supported by education, licensure and accreditation sectors, AAVMC Executive Director Dr. Marguerite Pappaioanou says. By all accounts, implementation represents an enormous task, and critics defending the current system note that such broad training fosters experts in recognizing emerging infectious diseases.

"This issue is so big and fundamental to the profession that it's hard to get your arms around," Pappaioanou contends. "I think a lot of this has to do with the belief that the profession is at a crossroads. There are all kinds of pressures out there to keep this from happening. That said, there's growing movement to implement change, and many people are excited about this."

Talks ensue

Dr. Leon Pielstick is torn. As a mixed-animal practitioner, he's been served by his inter-species education. Yet the Oregon Veterinary Medical Examining Board member is charged with drafting a legislative concept concerning limiting veterinarians' licenses to practice. Regulators plan to meet on the topic this month.

"I have James Herriot in my blood, so in some ways, I'm still sitting on the fence," he says. "At the same time, limited licensure seems to be a logical step. You can't cram all that education into four years anymore. We're taking a serious look at this."

The Council on Education (COE), AVMA's accrediting arm, also is exploring the issue, with plans to recommend creating a task force to study the Foresight Report and propose AVMA positions. The issue of limited licensure appears so contentious that AVMA leaders shunned three weeks' worth of DVM Newsmagazine interview requests to talk on the topic, apart from confirming that the Executive Board will consider the COE recommendation during its April 10-12 meeting.

In the meantime, AVMA's Board of Governors and the American Animal Hospital Association (AAHA) Executive Committee were scheduled to discuss limited licensure in Tampa.

"There are a lot of naysayers, and there are a lot of very clear-thinking people who agree with this idea," explains Dr. John Albers, AAHA executive director. "Limited licensure makes sense with a caveat that the veterinary education system must have multiple re-entry points. If someone followed an equine track and at some point decided to go back to companion animals, they could re-enter the veterinary curriculum at some point in the system."

Too soon

Yet Albers thinks that the profession is not ready for a limited-licensure overhaul. Dr. Don Klingborg, of the University of California-Davis' School of Veterinary Medicine, agrees.

"Licensing agencies have a big dog in this hunt because there's a lot of money to be made in this; people will want to leave their options open by taking more than one exam," says Klingborg, associate dean for Extension and Public Programs. "It also can simplify the life of a school if we take students in and can train them in one species. But I think people are using limited licensure to fix too many problems with one word. They haven't defined it."

Hurdles to implementing such a structure within veterinary education are multi-faceted, he explains. Meanwhile, colleges are getting beat up by various groups wanting more large-animal veterinarians.

"We have let a free-market system (influence) where people want to go, and it's led to an imbalance between small-and large-animal practitioners," he says. "There just isn't a level playing field. Emergency clinics have made the life of the small-animal practitioner a million times better. There's more money in it, a better lifestyle. That's not happening on the large-animal side."

The inequity has little to do with limiting the licenses of veterinarians, and considering the rise in graduates entering internships and residencies, Klingborg says that adding another year to veterinary programs is a more palatable way to pack in added education.

"A high percentage of new graduates are electing to accept more debt and add what's essentially a fifth year. So why are we then sweating bullets about this?"

Motivations

That idea doesn't fly with those in food-animal sectors, where rural salaries represent some of the lowest in the profession, says Dr. Anthony Knight, professor of Integrated Livestock Management at Colorado State University's College of Veterinary Medicine and Biomedical Sciences.

Set up correctly, limited-licensure programs can meet real needs in the profession, says Knight, who's watched his program dwindle during his 30 years on staff. "We still basically train along the lines of a generalist, and we've seen time and again, food-animal students come in and by the time they leave, they're small-animal veterinarians."

That pattern manifests in real numbers. According to AVMA statistics, large-animal veterinarian totals dropped to fewer than 4,500 in the United States in nearly two decades, representing less than 10 percent of the nation's private practitioners.

If veterinary medicine fails to produce more food-animal DVMs, Knight predicts the federal government will hire foreign practitioners to work in the nation's food-safety and agriculture systems. For that reason, limited licensure is encouraging, he says.

"I find the idea of trying to change the curriculum a positive for the profession," he says. "We could train a food-animal veterinarian with two years of medicine and an MBA in agribusiness and nutrition. Right now our students are coming out with $150,000 in debt, and people expect them to go into food-animal practice? It doesn't take a rocket scientist to realize this is a losing proposition."

Working against the system

Still, in a profession with manpower deficiencies in all sectors, limiting the scope of licensees will compound the problem, Klingborg says.

"The ultimate questions center on what our patients need," he says. "Do they need competent people who are professional only in one area or does their veterinarian need to be good at practicing general medicine? Does this country need more veterinarians? It's not a 'yes,' answer. It's a 'hell, yes' answer."

AAVMC's Pappaioanou admits that implementing limited licensure faces huge obstacles. Accreditation and testing issues aside, if colleges focus heavily on specific education areas and forego others to create "centers of excellence," for example, how will the institutions share students who want to learn more than one aspect of the profession? Where will their tuition dollars go? Will institutions need to redefine in-state and out-of-state residencies? And all of this hinges on the willingness of 28 accredited veterinary institutions to revamp their longstanding programs to divvy up aspects of veterinary education.

"How is licensure to be limited?" Klingborg asks. "There are no species more different than the cat and dog. And when you consider pocket pets and fish, I have to ask, 'what is our goal?' It ought to be better care. I just don't see, frankly, how limited licensure is going to better serve our patients."

Answers will come, but not easily, Pappaioanou counters.

"Is this going to happen in a single three-day meeting? No," she says. "But there's no question that all this is solvable. It takes people who are committed with leadership. It's a national dialogue that we need to have."

Conflicted

Despite Pielstick's personal reservations, he wants to start that conversation. He became motivated when an Oregon State University professor appealed to the licensing board, stating that an extra year of education was needed to teach mixed-animal practice.

"This professor was struggling with educating students in all aspects, and I thought to myself, 'We make the least amount of money. We can't afford another year of education,'" he says.

That's when Pielstick decided to explore limited licensure as a concept. Given his background, he's conflicted; an all-species edu-cation has enriched his career. Yet limiting the licenses of veterinarians seems inevitable, despite its drawbacks, he says.

"I think there's a younger generation that needs this and will be highly in favor of it. Small-animal students don't want to spend their time and money studying llamas and pigs," he says. "I think I'm a better veterinarian because of my broad training. That said, we're probably going to have species-limited licensure. I'm on board with that, even if it's a real sad thing for me."

That sentiment is typical among much of the profession, Pappaioanou says, noting that many times, the most serious policy issues are best tackled in smaller, more efficient state venues.

"They get something out there that works, and it spreads," she says. "Standardization comes when the federal government picks up on it. It's how things have worked in the United States for generations."