The rise and fall of the veterinary teaching hospital?

John Fredrick looked at the X-ray for several seconds. He then turned to Jennifer Adams and looked briefly over his glasses at a yellow Lab named Ben lying on the floor. John folded his glasses and laid them on the exam table. He was a robust man in his late 40s, and his normally jolly manner was now noticeably muted.

"Mrs. Adams, Jake has a mass growing in the femur — the long upper bone in the back leg."

He leaned over the table and tried to smile.

"The limp and consequently his pain seems to originate from this mass," John offered.

He waited a moment for all of this to sink in. Jennifer sat frozen to her seat and said nothing. John cleared his throat and continued.

"I have a good friend in Memphis, Dr. Sarah Jeffers, who is a boarded orthopedic surgeon. She also has an oncologist working with her. I would like to refer you there as soon as possible."

Jennifer slowly emerged from her glacial trance.

"Dr. Fredrick, we have always come to you all these years and trust you in every way. Is this something that you can do here? Could this be cancer?"

John had to bite his tongue. Ten years ago he would have either done the complete workup in his office or sent it on to the university. He quickly thought about the many legs he had removed in his career. He had to be careful.

"Mrs. Adams, I want only the best for Jake. In recent years, specialists have moved closer to a lot of the practitioners in the country and have brought state-of-the-art veterinary practice closer to our patients. Although cancer is a possibility, I cannot know for sure. The specialists are definitely in a position to give you more options than I can."

Jennifer nodded and took the referral brochure from John's hand. After they had talked for several more minutes, John emerged from the exam room and entered his office.

He always took a little time at mid morning to open his mail and make some callbacks. He went through the pile slowly and finally came upon a letter from the university. It was a referral letter from one of the clinical faculty at the veterinary school. The letter was well written, but the case in question had been sent to the university many months ago, and he would need to pull the chart and review the particulars.

John got up and closed his door.

The letter noted that Fuzzy Abrahamson, a blonde Pekinese, had been referred through the emergency room to an intern and subsequently to various doctors and then to this particular doctor — a Dr. Frances Simon on the medical rotation. Fuzzy had died after an exhaustive investigation and apparently several trips to the veterinary school for evaluation. There was a necropsy performed. The letter noted that the teaching hospital had not, as of yet, received the results of the necropsy from pathology.

John frowned. This was the first communication that he had received after the referral. Why was he getting this letter so late? He looked at the date of the letter. It had been written a few weeks ago.

John looked down the list of veterinarians that had seen Fuzzy. He did not know a single soul. He squirmed at bit because he knew Mrs. Abrahamson and hoped that the staff had treated her well there. She was nice but very particular.

John picked up the telephone and called the university. He asked for Dr. Simon. After a few minutes, another voice came on the phone.

"I am sorry Dr. Frederick, but Dr. Simon has just left the university for a position in private practice."

Dr. Frederick quickly fumbled with the letter and looked at the list of practitioners that had seen Fuzzy. After a few false starts, he was able to talk to one of the residents that had seen Fuzzy and was given a vague idea of what had happened. The resident was very pleasant and helpful but only could give part of the story due to the nature of the receiving situation at the university. He did say that pathology was backlogged, and a lot of cases were still in the tube. John thanked him and hung up.

As he hung up the phone, Judy walked in.

"Dr. Fredrick. For some reason Mrs. Abrahamson is taking her other pets to another veterinary hospital. She mentioned something about never receiving a phone call after Fuzzy's death."

Times have changed

While the veterinary medical institutions offer quality services, there is monumental change waiting in the wings at our nation's veterinary teaching hospitals that might be putting pressure on the system. The agricultural mission of our veterinary schools that fueled the expansion of our profession in the middle of the last century has gradually played out. Within the past 10 years, the state and federal governments have not seen fit to fund education and particularly veterinary education in a meaningful way. This is no doubt due, in large part, to governmental ambivalence to the dominant companion animal paradigm that has now emerged.

It now follows that a crisis has emerged in our veterinary schools with no solution at hand. The key issue is that most of the teaching hospitals are not able to attract and keep the faculty and specialists they so painstakingly produce. Some of the best and brightest are leaving the public sector to work in the private sector. The allure of higher salaries and freedom from the politics inherent in our halls of learning seem to have won them over.

It's about people

Twenty years ago, a graduate from a given veterinary school will have made many friends among the clinical faculty of his or her alma mater. This faculty usually stayed in place in the same institution for many years and continued to mentor these graduates for years to come. Because of this connection (and also because there were much fewer private specialty practices in the country) the teaching hospitals were the main referral centers for most of the nations private practitioners. The university could afford to be a little aloof and proud — they were for the most part the only show in town.

It should be noted that in those days, as well as today, all things being equal — people refer cases to people, not to institutions. The main impetus for referral has always been a bond of trust between the private practitioner and the specialist at the other end.

Career moves that are opportunities for faculty become a negative for the referring veterinarian as they inject uncertainty into the referral process. In addition, many faculty and residents are from out of state and do not have a ready network of in-state veterinarians from which to receive referrals. It may not even occur to them (or the university) that this may be an issue.

For many of today's practitioners, once they are out of school for more than a few years, they know only a small fraction of the faculty their predecessors knew after a similar time away from the university. It follows that if veterinarians do not know anyone at their alma mater, then it becomes simply a faceless university bureaucracy.

The process

Very often, referrals to veterinary teaching hospitals start with a phone call to a student or other non-decision making individual within the university. Many times, I have been told to send the patient on up, and that is the last I hear until my client actually tried to contact me about the case at some point later in the process.

I have found that there are many university faculty specialists that are quite happy to speak about a case that I may or may not send up to the university. Nonetheless, the process that evolves from that point on can be like sending a space probe to Mars without a radio — you just hope it lands and everything eventually is going to be all right. Sometime later, you may eventually make contact with your space probe — but then again, maybe not.

A world of possibilities

Today's veterinarians are more prone to refer than ever before. Yet, referral numbers are reportedly down at the universities. Ultimately and ironically, if faculty leave and are not replaced and the role of teaching hospitals in the development of tomorrow's specialists is diminished or extinguished, it is the private referral practices and our clients that will ultimately suffer. The private sector by its very nature cannot afford under any circumstance to take on the task of teaching and developing specialists. So now is the time to talk turkey.

Innovative programs that pre-fund residencies for aspiring specialists may pave the way for the private sector to fill positions that lay dormant for years may be worth investigating. Partnering with humane organizations and moving some teaching hospitals into densely populated cities may be an answer.

The time is now — waiting is not an option. Forming a committee is the usual university black hole. Selecting a task force is the usual AVMA/AAHA unending maze. Why don't we just have a good ol' 'Chautauqua'? — with tent and popcorn and just talk face to face. We might just find a way out of this mess.