Principles for specialist, generalist unveiled

NATIONAL REPORT — As the profession evolves, so do two distinct factions — its army of general practitioners and a growing number of board-certified specialists.

The result: veterinarians are sharing cases like never before, creating working environments known to challenge professionalism and collegiality. To address the growing pains and ease friction, a committee of academicians, large and small animal veterinarians, general practitioners and specialists have issued a white paper slated at presstime for publication in the April 15 issue of the Journal of the American Veterinary Medical Association (JAVMA). The Northeast Veterinary Liaison Committee (NVLC) offers the profession's first comprehensive guidelines for general practitioners and board-certified specialists to enhance communication, public trust and medical care.

Written on the back of encounters with collegial breakdowns, Dr. Gary Block seeks to hammer out universal principles in a document he describes as "largely common sense." The project's brainchild and owner of a 25-doctor Rhode Island referral practice says the history of friction between specialists and generalists needs to be addressed.

Written on the back of encounters with collegial breakdowns, Dr. Gary Block seeks to hammer out universal principles in a document he describes as "largely common sense." The project's brainchild and owner of a 25-doctor Rhode Island referral practice says the history of friction between specialists and generalists needs to be addressed.

"The nature of veterinary medicine is changing very rapidly with the growth of all these tertiary veterinary facilities outside of universities," Block says. "It's a lot of pressure — too many hospitals or not enough veterinarians. Each hospital is trying to get its slice of the pie, and that makes for a very delicate relationship."

Communication guidelines

It's a fragile bond on several levels. While specialists rely on patient referrals from general practitioners, case co-management is a recipe for hostility, Block says. Whether it's diagnoses doubts, attitude issues or allegations of patient theft, communication often is the answer, he adds, although it's not always practiced as needed.

"The American Veterinary Medical Association's principles of veterinary medical ethics is fairly limited in how specialists interact with general practitioners," Block says. "With so many doctors and hospitals responsible for patients' care, unless we have good communication with animal interests first, public trust and animal care would suffer."

While it might appear like common sense, good communication starts with clear, legible medical records using only the widely accepted abbreviations and notations for medical errors, the paper says. It's the referring veterinarian's responsibility to fax or mail medical records to the client. The veterinarian also should make every effort to provide the specialist with records by initial referral appointment, the paper adds.

It's then the responsibility of the specialist to keep the general practitioner apprised of the case. If an animal dies or is euthanized, the specialist should notify the referring practitioner immediately so he or she can provide the client with grief counseling.

While the referring veterinarian transfers primary case management and responsibility to the specialist, he or she is encouraged to call for updates on diagnostic testing and therapeutic decisions. The specialist should answer those calls immediately or a return call should be made the same day. Referral letters including any diagnostic findings, plans for follow-up care, and some indication of whether it should be performed by the referring veterinarian should be mailed within one week of discharge or death of any referred patient. Instructions should be faxed to the referring veterinarian the day the patient is discharged, the paper says.

Such guidelines might seem obvious, says Dr. Anna Worth, a Vermont general practitioner and the American Animal Hospital Association's (AAHA) vice president. But when problems arise, they're likely linked to communication gaffes.

"It's a topic in each person's face these days," says Worth, who contributed to the paper as an NVLC member. "It's about understanding each other's point of view. The bigger picture is our profession is going to benefit by having specialists and generalists bond. I'm all for us working together."

Etiquette issues

There are no strict rules guiding when to refer a case; the decision is "complicated and multifactorial," the paper says, adding that any animal that "has not received a definite diagnosis or fails to improve despite medical treatment should be considered a candidate for a second opinion."

But the paper also addresses protocols for phone-managed cases, specifically when a general practitioner seeks advice from a specialist without referring the patient.

"Some general practitioners will never refer a case but call a specialist and phone manage," Block says. "That's not fair from the specialist's perspective. The general practitioner should respect the specialist's time and not try to phone manage what should be a referral. The general practitioner should be notified if the specialist has to charge for the consultation."

On the other hand, specialists have an obligation to be educators, and fees often aren't well received by general practitioners. "Over 50 percent of the consults I do, those specific patients don't get referred," he says. "But there are always a tiny percentage of veterinarians who take advantage of that relationship."

Swiping clients

In addition, specialists should not take advantage of referring veterinarians by stealing cases, the paper says. They have an obligation to refer back to the general practitioner as a case's management is underway.

"To maintain a constructive and collegial relationship and in the interest of fostering a long-term mutually beneficial and financial equitable relationship, veterinarians from the specialists hospital should refrain from becoming the general practitioner for the referred patient," the paper explains. A specialist should never offer vaccines, heartworm testing and preventives, annual examinations or flea and tick products, the paper adds, although rabies vaccines can be considered an exception in some circumstances.

If clients demand such services and express dissatisfaction with a referring veterinarian, the specialist should encourage communication between both parties to maintain the veterinarian-client-patient relationship. The same goes for specialist complaints, the paper adds.

Tight rope

But when grievances include negligence or malpractice, the specialist-generalist relationship can get sticky, Block explains.

While owners have a right to honest answers when asking a specialist for his or her opinion concerning a case's management, specialists should not make comments "that in any way impugn the reputation or undermine the client's trust in the referring veterinarian without first reviewing the medical record and contacting the referring veterinarian to discuss the case," the paper says.

"It's pretty much an unwritten rule that specialists tap dance and avoid telling the truth when they feel the case is mismanaged," Block says. "Their livelihood depends on the general practitioner's referral. We're saying that if the intent is good and the medicine is adequate, call the general practitioner first and be tactful. But if cases rise to the level of gross malpractice and the client asks you about it, you're in an awkward situation."

If a veterinarian continues to make egregious mistakes, colleagues have an ethical obligation to report malpractice, Block adds.

"I don't think that happens, in part because there's a blue wall mentality; it's never been something our profession has really addressed," he says. "But if the public gets wind of the fact that we are not self-policing, we will not be trusted. We are not going to tolerate negligent care and malpractice."

Left unsaid

Conspicuously absent from the guidelines are issues of direct-to-consumer solicitations from specialty practices and whether or not general practitioners will remain gatekeepers for specialists in the future.

The paper notes the committee's "interest in brevity" and acknowledges the need for more discussion on specialist-generalist relationships. As for specialty advertising, that's another issue. In the meantime, Block's certain the paper will incite debate.

"I think there will be plenty people who will read this and fill up the JAVMA editorial pages with non-collegial comments. And that's OK," he says.