Specialist, generalist bond dictates level of care

Dr. Tom Mann, Akron, Ohio-based general practitioner, admits to a bit of surprise after reading a letter sent to his colleagues by another general practitioner.

The letter, from an unnamed three-person private practice, advertises such services as endoscopy, ultrasound and bone plating, further stating, "We're willing to take cases that general practitioners don't want to send to expensive specialists."

It's that last line that unsettles Mann, and underscores what he views as evidence of a potential fracture between specialists and generalists.

The relationship between the generalist and specialist, he says, is in a state of evolution in the profession, as more specialists open up shop in urban and suburban America.

Specialists comprise a growing segment of the profession, and it's critical to ensure strengthened communications between the two groups to avert gaps in serving the human-animal bond, adds Dr. Brian Forsgren, who, along with Mann, helped lead a discussion on the specialist-generalist relationship at the Midwest Veterinary Conference in late February.

"This evolution of veterinary care delivery necessitates a well-thought out dialogue between the general and specialty practitioner," Forsgren says. "Understanding the dynamics of this emerging phenomenon will help us all take our capacity to serve our patients and clients to a new level."

The way we were

Mann says his career spans a time when the only specialists around were at the university, if veterinarians were in a state fortunate enough to have a veterinary college.

Ultimately that meant Mann and many of his colleagues did their own joint surgeries; they fixed broken bones all the time.

"Now I have a group in town that ostensibly can do it better than me. Do I quit or continue?" Mann rhetorically queried. "If I can do it well, OK. If not, can I have sense enough to refer?"

Mann says some, albeit isolated, segments of specialists across the United States have been raising voices in the past few years that general practitioners are doing things they shouldn't and that they should be referring cases sooner.

"Now they're taking it public: General practitioners are not referring soon enough. By the time the specialist gets the case it's too late. That tends to be a little offensive to some segments," he argues.

The goal of the discussion was to find out the prevalence of such concerns to specialists and general practitioners.

Not everyone agreed, however. Dr. William DeHoff of MedVet Associates in Columbus, who attended the session, says he hasn't experienced any breakdown in the referral process. "For me the relationship with the private practice for the specialist on a collegial level is very enjoyable."

Communication is key

Yet DeHoff concedes it's strong communication that fuels that relationship, and encourages any referring veterinarians with problems to call him.

While better communication would be ideal, often general practitioners are left with much less, according to Dr. Cynthia Bowlin, a general practitioner in Columbus.

"Sometimes specialists can have a judgmental attitude toward generalists. Some have communication problems and lack public relations skills," she says.

Is gap for real?

Dr. Barry Kipperman, specialist in San Ramon, Calif., argues the unwritten gap between general practitioners and specialists is only a perception.

"Remember both groups are for-profit endeavors," he says. "The first step toward a better relationship is asking whether specialists and general practitioners acknowledge their limitations. Respect those limitations. Specialists don't know the pet's history."

Adds Dr. Jim Prueter, specialist in Grafton, Ohio: "We're not here to battle. Specialists are extended arms to general practitioners."

That said, Dr. Brian Huss, a Massachusetts-based boarded surgeon, notes that the rivalry he's viewed between specialists and generalists tends to occur among older practitioners.

"The older practitioners had to learn to do things on their own," he says. "Newer practitioners are being taught that they're expected to refer. With today's litigious society, you have to be willing to refer."

Money factor

What if a generalist says he or she can do a procedure for much less than a specialist would? Huss counters, "Obviously that general practitioner is not charging appropriately for his or her own services. Secondly, if they were doing that on a regular basis, they'd be losing money and would eventually go broke."

Many practitioners, according to Huss, don't realize how much surgery costs them. He says they use spays and neuters as loss leaders to get patients cared for.

"As a specialist, surgery is all we do so we know what we need to charge to be able to pay for appropriate equipment and staffing. That's why they feel we're charging more than they do."

Malpractice dilemma

Another issue of division during the session was the topic of malpractice.

Dr. Gary Block, an internist in Rhode Island, asked, "If I think malpractice has occurred on the part of the referring vet, is it my responsibility to smooth things over and protect the veterinarian, or do I answer the client and say, 'yes, I think this is malpractice' and report them?"

Deb Prescott, DVM, Ph.D., dipl. ACVR, radiation oncologist in Columbus responds: "The way I look at it, I wasn't there when the vet did the exam. Things can change in a rapid period of time, such as tumors."

There's a fine line between malpractice and a bad accident, Prueter adds. "Each one of us has made serious errors. It's when the same mistake is repeated again and again that it becomes an issue."

It's important that the referring veterinarian is given fair chance to explain, Bowlin says. "If they're seriously a risk to the general public, then you should report them to appropriate authorities."

Malpractice in many cases is actually misunderstanding, DeHoff says. "More often than not, the client feels somebody has to pay for it, even if it was not something that was done wrong. Most cases are breakdowns in communication where the veterinarian did not talk to the client thoroughly enough."

One legal advisor to the veterinary profession says that what's difficult with the hypothetical malpractice instance is that there are no standards in veterinary medicine.

"The key to dealing with such an issue is mentorship. Specialists should be mentors to generalists," says Charlotte LaCroix, DVM, JD.

Bottom line

Specialists, such as Dr. Milt Wyman, a veteran board-certified ophthalmologist in Worthington, Ohio, hope veterinarians never follow in the footsteps of human medicine. "Specialists want to feel a part of the general practitioner's practice," he says. "We should be in it for the human-animal bond and providing the best care for the patient."

DeHoff adds, "I wouldn't let the few percentage of specialists who are angry or the practitioner who's angry get in the way of a healthy relationship."