A not-so-special specialty referral

Dr. Leah Susa owns a three-doctor small animal practice in a suburb of Cincinnati. She grew up in the area, graduated from Ohio State's College of Veterinary Medicine and now 12 years later is a practice owner. She attributes her success and her loyal clientele to the practice of honest and ethical veterinary medicine. As is the case with most clinical private practitioners, she finds certain areas of veterinary medicine more interesting than others. Dr. Susa's interest is surgery. She is not a boarded surgeon but prides herself on her ability to do complex successful surgeries aided by her many postgraduate surgical seminars. 

Rover, an 8-year-old Lab, comes to see Dr. Susa with an inflamed left eye and a large ulcerating mass on his left rear leg. Dr. Susa determines that Rover has acutely injured his eye and a corneal perforation is evident. The mass seems sebaceous in nature and will have to be dealt with eventually. Dr. Susa tells the owner, Mrs. Talmage, that the dog needs to go immediately to a veterinary ophthalmologist so the eye can be saved. After the acute eye is controlled she will surgically remove the leg mass and biopsy the tissue to confirm her suspicion of its benign nature. 

Dr. Susa has her staff contact the closest veterinary specialty center, which is located about 20 minutes away. She speaks to the ophthalmologist, Dr. Toms, explaining the dog's eye injury and the urgency of the situation. The owner is instructed to come right away.

The ophthalmologist evaluates the eye and schedules Rover for reparative surgery. He also notices the ulcerating leg mass and discusses it with the pet owner. Mrs. Talmage asks the ophthalmologist if it would it be possible for one of the specialty center surgeons to remove and biopsy the draining mass while Rover is under anesthesia. This will allow everything to “be done under one roof,” as she describes it. Dr. Toms says he is sure Dr. Susa can take care of that surgery at a later date, but the pet owner is insistent. Rover undergoes both procedures that day and does beautifully. 

The following week Rover returns to Dr. Susa for suture removal and a recheck. Dr. Susa is livid. She does not confront the pet owner but complains to colleagues at her clinic that the other hospital performed a surgery for which the dog had not referred. She calls the specialty center and demands to know why a soft tissue surgery was performed when she sent the dog for an ophthalmology consult.

The hospital director responds that the specialist informed the pet owner that the mass could be removed by the referring veterinarian but the pet owner insisted, so the referral hospital had no choice but to honor her wishes. Dr. Susa is civil but vows not to refer to that specialty facility again. She feels it was unethical for a referral hospital to render services to her client that went beyond the scope of the referral. 

Is Dr. Susa justified in being upset with the specialty hospital?

Rosenberg's response

It is the expectation of the referring veterinarian that when he or she obtains a specialty service, the patient will be returned to the referring doctor for services outside of the scope of the referral. This maintains an amicable referral-specialist relationship. When the referral facility “keeps” referred patients, the relationship quickly sours. Short-term client acquisition leads to long-term referral losses. 

In this case, the ophthalmologist should have called the referring veterinarian and explained that the pet owner had asked if she could also have the pet's surgery done at the specialty facility. This would have given Dr. Susa an opportunity to speak to the client and help finalize the ultimate decision. In the end, the client's wishes must be respected. If she chooses to have all her veterinary care done at the specialty referral facility, it is her choice. But the specialist needs to make an effort to advise the referring veterinarian of the situation and make it clear that there has been no solicitation of the client.

Dr. Marc Rosenberg is director of the Voorhees Veterinary Center in Voorhees, N.J. He is a member of the New Jersey Board of Veterinary Medical Examiners. Although many of his scenarios in "The Dilemma" are based on real-life events, the veterinary practices, doctors and employees described are fictional.