Working together to maximize spectrum of care

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As veterinary medicine becomes increasingly specialized with advanced diagnostic and therapeutic measures, clients have more options for their pets than ever before. However, advanced options aren’t always the best fit for each client and patient, because certain limitations can arise. Some examples may include limitations related to finances, time, physical abilities, or goals for their pet’s life. Veterinarians must collaborate with clients along a spectrum of care to find the best option for each case. Specialists and general practitioners (GPs) can work together to maximize outcomes for patients within this paradigm.

What is the spectrum of care?

The spectrum of care is the concept that a range of diagnostics and treatment options exist for any given condition. These vary from more invasive, expensive, and extensive options on one end to less invasive and more affordable options on the other, with a myriad of options in between. One option is not inherently better than another just because of where it falls on the spectrum.

For example, take a young adult dog who presents with new seizure activity. Diagnostically, the gold standard would have the client pursue referral to a veterinary neurologist for advanced imaging and other testing to achieve a definitive diagnosis. An alternative option would be to run initial diagnostics, such as lab work, to rule out extracranial causes and discuss differential diagnoses and monitoring for future seizure activity with the client. Medical therapy may or may not be instituted, depending on the severity and frequency of the seizure activity. Both options are reasonable approaches to a patient presenting with seizures, especially when history, signalment, and physical examination findings point to a likely diagnosis of epilepsy.

Practicing within this spectrum allows veterinary teams to work with individual pets and clients to determine the best fit both diagnostically and therapeutically. This allows the care team to maximize patient quality of life within the confines of patient temperament, client limitations (which may be financial, emotional, or physical), and goals while fulfilling the veterinary legal, moral, and ethical duties.

For some experienced veterinarians, the spectrum of care is how they have always practiced, but the concept must be explored more thoroughly in the profession as the range of options that can be offered widens. Veterinary students still only attend 4 years of school, and much of their education focuses on academic approaches to various diseases. Many new veterinarians are not equipped with the confidence or practical knowledge to provide alternatives, necessitating conversations about a spectrum-of-care approach.

The role of the gp

GPs are the first doctors that many pets see during an illness. These veteri- narians should be comfortable with providing a range of options for clients and working with the client to determine the best option in the current situation. Clear communication is essential to achieve this goal. For each option, veterinarians must be able to explain to clients the reasons behind each recommendation and what a client might be giving up by declining. Throughout the discussion, veterinarians and team members must remain empathetic and remember that the option the client chooses is influenced by many factors. Choosing a less extensive option is not a reflection of the strength of the bond between client and pet.

In cases that are more complex, specialty referral should be considered. Barriers to referral care include financial constraints, travel restrictions when specialty care is hours away, availability of specialty appointments, and concerns about pursuing invasive options. Even when a client is unable to pursue advanced options, specialists may still help guide the case direction by offering an additional perspective.

Finally, it is important for all clinicians to remember that most clients and pets may move up and down the spectrum of care at any time, based on the current circumstances in the life of the family, the condition of the pet, and past experiences with previous pets. Although a client may seek specialty care to obtain a complex work-up early in their pet’s life, they may not have an interest in the same pursuit later in that pet’s life, especially if the prognosis is poor or their family circumstances have changed.

The role of the specialist

Specialists are typically called on for a second opinion or because they offer more advanced diagnostic tests or treatment options that are not otherwise available. Some pets are referred to specialists directly from the GP, whereas others are transferred for specialty care after being admitted to the emergency department.

A specialist’s primary responsibility should be to add value to the veterinary GP-client-patient experience. Specialists should be considerate of the existing bond among pet owner, pet, and veterinarian and have a unique responsibility to establish connection with all 3 members of the existing triad, adding another dimension to patient care (Figure).

Figure

Specialty medicine starts at the initial consultation. Specialists are often better suited to explain the reasons behind advanced recommendations. Like GPs, specialists must also be comfortable providing a range of options for clients and working with them to determine the best option, and they should remain empa- thetic and remember that the option the client chooses is influenced by many factors. The veterinary practice oath taken by both specialists and GPs alike includes the statement: “I will practice my profession conscientiously.”

Working together to improve patient outcomes

Collaboration allows for veterinarians to work together and share the conversation and educational burden. Although GPs have a broad knowledge base across many disciplines, specialists have a specific and deep expertise in their chosen area of practice, so they can best describe the details and nuances of advanced options to clients interested in this route.

To successfully share client education and case management fully, trust must be established among all parties in the collaborative care pyramid. Both successful and unsuccessful case outcomes are to be shared among all members of the health care team. Each member of the team must also hold others accountable. It is reasonable to expect clear, timely communication, especially during comanagement of a case. Ensuring complete records are passed from one clinic to another, including prescriptions and client communication, is essential for success.

Specialists should encourage clients to return to their primary veterinarian once initial diagnostics and treatment have been completed, because this can decrease costs and minimize stress on the patient and client. Although GPs may initially feel overwhelmed by this idea, developing comfort with continued case management should be a priority. Specialists and GPs should discuss the roles and responsibilities of each in the management of a mutual case. With the growing use of telemedicine, teleconsultations are likely to become more widely available, which will create an alternative revenue stream and a more flexible working environment for specialists while allowing GPs to receive guidance on care for specific patients. Ultimately, collaborating on cases will help to guide owners to the best decision for their individual pet within the limitations of their circumstances and maximize patient outcomes while working together within a spectrum of care.

Kate Boatright, VMD, a 2013 graduate of the University of Pennsylvania, is a practicing veterinarian, freelance speaker, and author located in western Pennsylvania. She is passionate about mentorship, education, and addressing common sources of stress for veterinary teams and recent graduates. Outside of clinical practice, Boatright is actively involved in organized veterinary medicine at the local, state, and national levels.

Heather Kvitko-White, DVM, DACVIM (Internal Medicine), is a board-certified small animal internal medicine specialist and national speaker who teaches veterinarians and organizations a commonsense approach to improving patient outcomes while managing costs. Often helping to bridge the gaps among academia, industry, and practice, she develops and delivers pragmatic medicine content at all industry levels.