Specialists and general practitioners share limitations

What are the limitations of general practitioners (GPs) and specialists?

About a year ago, I saw a dog referred for severe immune-mediated thrombocytopenia. The dog spent about a week in our hospital, receiving around-the-clock care due to severe GI bleeding and resultant anemia.

The PCV was about 10 percent despite multiple transfusions. I discussed the risks, merits and costs of remaining options with the client, and a mutual decision was made to proceed with splenectomy. I scheduled the procedure with a board-certified surgeon, and called the referring veterinarian to provide an update.

After a thorough discussion of the dog's weak condition, severe non-responsive thrombocytopenia and duration of illness, I informed my colleague of the recommendation to proceed with surgery. His only comment was, "I can do a splenectomy here"(e.g. at his hospital). I politely agreed that I'm sure he was capable of doing the procedure, and inquired if there was any other rationale for moving the dog to his hospital for the surgery.

Barry Kipperman, DVM, dipl. ACVIM

At this point, I felt stuck in the middle between pleasing my colleague who referred the case, and my advocacy to the pet whom I felt would not benefit from being moved back and forth. We decided that I would offer the client both options, ensuring she knew that surgery with the specialist would be more costly, and let her make an informed decision. At the end of the conversation, I jokingly told the veterinarian that I could also have considered doing the splenectomy. He responded by saying, "You can't do surgery; you're a specialist in internal medicine. I, on the other hand, can do everything; surgery, medicine, oncology, dermatology and ophthalmology."

By performing a residency and becoming board certified, most specialists have overtly acknowledged their strengths and limitations; that is, I would never consider performing major surgery on someone's pet for multiple reasons:

• I'm a lousy surgeon, and haven't performed major surgery since my internship.

• My patients have better options available.

I would be liable to the standard of care available in our community if I did the surgery, and did not provide the client with all available options.

In fact, when I do diagnose surgical disease in my client's pets, they often ask me "Will you be doing the surgery, doctor?" I often chuckle at the thought, and respond, "You don't want me performing this surgery. We will put Muffy in the hands of a specialist at these types of procedures."

I got the impression that the referring veterinarian in this case saw very few aspects of medicine and surgery that he felt he was not an expert in. What factors should influence the decision as to when a GP should consider that he/she may not be the one best suited to care for a particular pet?

Practitioner limitations

• Ego: It is very difficult for some of us to acknowledge that we have weaknesses and frailties. This is especially so when in fact we are licensed to do all things to most non-human creatures. In addition, many of us are solo practitioners. Heck, who else is around to do it, but you? Your staff worships you, and trust you with their own pets. You are the self-proclaimed king of your castle (hospital) aren't you? Could years of practicing by yourself have lulled you into a false sense of autonomy about your skills? Can you recognize when you don't have the time or skills to best suit the medical needs of your patient?
• The golden rule: I was speaking with a new graduate on a flight en route to a national meeting. He told me he was excited about the prospect of performing his first cruciate surgery after the meeting. I inquired as to whether he had done the surgery before, or was to be supervised by a more experienced colleague. To my chagrin, the answer to both questions, was, "No". Yet, he seemed to have no moral reservations in his opinion. Would you want this level of care for your ACL if you needed surgery? Does this mindset fit your mission statement? I suspect we suffer from a severe case of the "If I can, I should, and I will" syndrome.
• Peer pressure/liability: Our missed diagnoses and mistakes are not revealed by an autopsy on every patient; we do not routinely examine "what went wrong" in a peer-review forum as our human counterparts are encouraged to do. In addition, given the property status of pets, our liability vis a vis economic pressures is negligible. The minimal influence of peer pressure and financial damages discourages a strong sense of medical accountability on the part of veterinarians.
• Severity of patient illness: I believe that the more advanced/severe the patient's illness, the greater the expertise that patient requires for a successful outcome. To continue with a surgical analogy, I would argue that the relative expertise of the surgeon performing an ovariohysterectomy is generally irrelevant, as the young healthy pet is apt to recover well almost regardless of the duration of surgery. In fact, by virtue of their greater experience, most GPs probably would whip through this surgery faster than a specialist surgeon. Yet, the same cannot be said for the dog in our example in need of a splenectomy with a PCV under 10 percent. You should hold yourself to greater scrutiny as a patient's condition worsens.
• Availability of specialists/facilities: The greater the availability of 24-hour monitoring, the more obliged you are to offer this option to clients whose pets may benefit from this level of care. If you are the only veterinarian within 60 miles of a dog with GDV, guess what?The buck stops here!

Alternatively, if you operate a GDV, and the dog dies unobserved overnight two miles away from an emergency hospital, it looks bad if you didn't discuss/encourage this option.

The limits of the knowledge of the specialist can be a double-edged sword. While he/she may be the best person for the job to treat the patient's Cushings disease, the specialist may ignore or diminish the impact of the old-age arthritis that treatment has unmasked on the pet's quality of life.

Specialist limitations

Surgeons have often been accused of rushing to cut. Is the surgeon the best person to ask whether an asymptomatic 14-year old Golden Retriever with hepatic masses should undergo a hepatectomy?

• Specialists are not the family vet: By virtue of the client's long standing relationship with the GP, the GP is often in a better position to help guide the pet owner through the maze of difficult decisions inherent in the process. The trust that has been built over years with the GP cannot be rivaled by the specialist, where the duration of interaction with one particular client is often brief. Using the above example, the internist might call the GP to discuss how well the Cushing's disease is controlled. The GP may bring the specialist back to earth with a reply such as "That may be, but I saw the dog today, and she can barely walk. I know this will not be acceptable to Mrs Jones. What should we do about this?" The specialist may see the dog as a walking hyperplastic adrenocortical cell that needs to be lysed, while the GP may be more apt to see the bigger picture. As a result of putting their heads together, a mutual decision may be made that the dog is better off without treating the Cushing's.
• Specialists often don't know the client's background as well as the GP.

Let's consider two scenarios.

Mrs. Smith brings her dog to the oncologist for consultation on a diagnosis of lymphoma. No phone call or paper work is available to the specialist prior to the client's arrival. Generalized lymph node enlargement is confirmed. As soon as the specialist mentions the word chemotherapy, Mrs. Smith becomes very upset, and proclaims that she would never do that to her dog, and storms out of the exam room. The oncologist staggers out of the room, wondering what could possibly have elicited such an irrational, negative reaction. The referral letter is written later that day.

Mrs. B is the next appointment. Her dog has the exact same problem, but her visit is preceded by copies of the cytology confirming the lymphoma, as well as a phone call in which the GP informs you that Mrs. B just lost her brother to cancer and she perceives that chemotherapy was detrimental to him.

You broach the topic of chemotherapy very gently, taking pains to make clear that the goal is an emphasis on quality of life, that lower doses are used, and dogs seldom are made ill. The chemo is elected, and the dog does well.

The knowledge about the client that is privy to the GP is often of significant value to the specialist in helping to ensure compassionate and effective medical care of the pet.

Are there specialists who violate these rules?

You bet. Are there general practitioners that appreciate and acknowledge their limitations, and refer based on this insight? For sure.

Yet, by their choice to limit their career area of expertise, I believe that specialists are more apt to appreciate their respective strengths and limitations, than are general practitioners.

This is not to suggest that there is a difference in empathy or consideration between the two groups. I simply believe that the onus to respect one's limitations is greater on the part of the general practitioner, because this must be governed by your conscience and an objective evaluation of your professional strengths and weaknesses.

When the general practitioner and the specialist appreciate the boundaries of their respective areas of expertise, communicate well and work as a team on behalf of the best interests of the pet, the well-being of our patients is best served.