Archive for August, 2011:

Upton Sinclair
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Referral to a Specialist: Your freedom to choose (Provided you ask the right questions)

By admin On August 26, 2011 - 0 Comments

 

“It is difficult to get a man to understand something when his job depends on not understanding it.”

Upton Sinclair  US novelist & socialist politician (1878 – 1968)

This could perhaps be paraphrased

 “It is difficult to get a man to promote something if his income depends on not promoting it”

If your NHS doctor refers you to a specialist, she does not lose out on income as a result.  If your veterinary surgeon offers referral for your pet, he (or his employer) inevitably loses the income from the further investigation and treatment of your pet’s illness which goes to the referral practice and not to the practice of the referring veterinary surgeon.  Your vet is therefore inevitably conflicted.  Fortunately, in our experience the vast majority of veterinary surgeons are ethical individuals who have a strong sense of integrity and the welfare interests of their patients at heart.  However, there are great financial pressures on everyone these days and no barrel contains only good apples.  Furthermore, there has been a growth in corporate practices over the last few years and the conflict for veterinary surgeons employed in corporate practices is perhaps greater since a veterinary surgeon working for a corporate practice may be under some pressure from his paymasters to retain business within the corporation rather than to refer elsewhere even if the latter action is ultimately in the best interests of the animal.

In recent years, we have become more aware of cases receiving inadequate treatment with an unsuitably qualified individual when the offer of an earlier referral to a suitably qualified specialist would have been more appropriate for the animal and almost certainly more cost effective for the animal’s owner.  In some practices a trend has developed to have “visiting specialists” or “in house specialists” but these individuals are not financially independent of the referring practice and are often not as well qualified as they might be, nor are they supported by all the other specialist services that might be present at a specialist referral centre. Click here to read more about appropriate specialist veterinary qualifications and here to read Justin’s seven questions.

The Royal College of  Veterinary Surgeons (RCVS – http://www.rcvs.org.uk/ ) publishes a Guide to Professional Conduct (the “Guide”) which is the “rule book” by which all veterinary surgeons operate and against which any vet can be brought to account by the disciplinary procedures of the RCVS.   In the sections that follow, excerpts from the Guide are highlighted in blue and italics.

The Guide contains the following advice on the relationship between veterinary surgeons and their clients:

The professional/client relationship is one of mutual trust and respect, under which a veterinary surgeon must:

a. maintain client confidentiality
b. treat the client with respect, and observe professional courtesies
c. avoid conflicts of interest
d. give due consideration to the client’s concerns and wishes where these do not conflict with the patient’s welfare
e. provide fully itemised accounts if requested.

 

So, “a veterinary surgeon must avoid conflicts of interest” with their clients, but immediately any animal is considered for referral, that veterinary surgeon is placed in a position of conflict, since income may be lost to him or his employer if a patient is sent to another practice.  The poor vet cannot help but contravene the letter of this regulation.

The problem is epitomised by the quotation from Upton Sinclair at the head of this blog.  Why would a veterinary surgeon promote referral when in doing so he will lose income?  Given this inevitable risk of a conflict one might expect that the RCVS has solid governance in place to ensure that the conflict is resolved only in the interests of the client and the animal.  The emphasis in the “Guide” is perhaps not quite as much in favour of the animal owner and the animal as one might expect.

Whether or not a case is referred is agreed by discussion between the client and his usual veterinary surgeon

Note that that there is no requirement for the veterinary surgeon to “initiate a discussion about appropriate referral when this is in the interests of the animal’s welfare”.  If the client does not initiate the discussion, then the vet may be absolved of responsibility just by keeping quiet.  A veterinary surgeon looking after his own or his employer’s income might well keep his head below the parapet and not initiate such a discussion unless pressed by the owner.

Veterinary surgeons must not:

a. speak or write disparagingly about another veterinary surgeon

b. obstruct a client from changing to another veterinary practice

c. discourage a client from seeking a second opinion

 

Note again that this list is couched in terms of “must not obstruct” and “must not discourage” rather than perhaps a more appropriate, “must offer the client an appropriate option of”

Your own veterinary surgeon has a responsibility to provide you with all the information needed to make a proper and fully informed decision about referral.

Yet again, this statement embodies no onus on the veterinary surgeon to initiate the process even if this is in the interests of the animal, only a requirement to participate in providing information.

So, how do you ensure that your pet receives referral when it is appropriate to do so?  For a start, you should always ask your vet about referral if you think it might be appropriate.  You should also ask about the standard of qualification of any “specialist” that you might be referred to and in doing this you will need to understand the different types of specialist qualifications by following the link earlier in this blog

Finally, the “Guide” does contain a list of responsibilities that veterinary surgeons have to their clients written in terms of what they should do.  These are listed below and can be helpful to you.

The provision of veterinary services creates a contractual relationship under which the veterinary surgeon should:

 

a.      ensure that clear written information is provided about practice arrangements, including the provision, initial cost and location of the out-of-hours emergency service, and information on the care of in-patients

b.      take all reasonable care in using their professional skills to treat patients

c.       keep their skills and knowledge up to date

d.      keep within their own areas of competence save for the requirement to provide emergency first aid

e.       maintain clear, accurate and comprehensive case records and account

f.        ensure that a range of reasonable treatment options are offered and explained, including prognoses and possible side effects

g.      give realistic fee estimates based on treatment option

h.       keep the client informed of progress, and of any escalation in costs once treatment has started

i.         obtain the client’s consent to treatment unless delay would adversely affect the animal’s welfare (to give informed consent, clients must be aware of risks)

j.        ensure that all staff are properly trained and supervised where appropriate

k.       ensure that the client is made aware of any procedures to be performed by support staff who are not veterinary surgeons

l.          recognise that the client has freedom of choice

 

In the context of referral, the most relevant items in this list are items d, f and l.

 

Item d:  Your veterinary surgeon is required by the RCVS to be sure that he keeps within his area of competence.  You should have no qualms about asking your veterinary surgeon if work he is proposing to do is within his area of competence or whether it would be more appropriate to refer to a centre or individual with higher levels of qualification and competence as recognised by the RCVS.

 

Item f:  Your veterinary surgeon is required by the RCVS to discuss a range of reasonable treatment options with you.  It is always reasonable for you to ask if these options should include consideration of referral to a suitably qualified specialist.  Your veterinary surgeon also has a responsibility to discuss fully with you the different levels of qualification that a given specialist has, but will only be obliged to do so if asked directly about this so you should be sure to familiarise yourself with these through the link earlier in this blog.

 

Item l: Your veterinary surgeon is required by the RCVS to recognise your freedom to choose who treats your animal.

 

Specialist veterinary services can be expensive, but your vet should be able to contact the chosen referral centre to obtain an estimate of costs for you before referral.  Remember, that your own veterinary surgeon may not have much incentive to start a discussion about all of your choices for referral and may also not have an incentive to discuss the standards of qualification of an individual or centre that he refers to unless asked directly.  Remember also, the Upton Sinclair quotation from the start of this blog.  Don’t be afraid to ask your veterinary surgeon about referral to a suitably qualified specialist if you think this might benefit your pet and don’t be afraid to ask if the referral centre or individual under discussion is independent or whether there is some form of financial benefit for your own veterinary surgeon or the company that he works for.

 

Ultimately, you have the freedom to choose who treats your pet and if you want this to be a properly qualified specialist (Diploma holder or RCVS Recognised Specialist) then your veterinary surgeon is obliged by the RCVS to assist you in locating such an individual, but only if you ask him or her to do so and only if you are specific about your requirements.

 

 

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Specialistblogpic
Feature

Is my veterinary specialist a proper specialist?

By admin On August 11, 2011 - 0 Comments

This problem is complex.  Read on to get the detail, but be warned you may get a headache trying to understand it.  If all you want to know is how to recognise the best qualified specialist for your animal then skip to the last paragraph

The online dictionary “Ask Oxford” defines the word “omnicompetent” as meaning “able to deal with all matters”.  This term is used to describe veterinary surgeons on the very first day that they graduate after 5 or 6 years of training at veterinary school.   This principle is enshrined by the Royal College of Veterinary Surgeons (RCVS) which is the “watchdog” responsible for setting standards in the veterinary profession and acting on behalf of the animal owning public. The principle is that all veterinary surgeons, from the very moment that they graduate are theoretically allowed to perform any act of veterinary surgery.  Imagine the same situation in human medicine; the fresh out of the box, still wet behind the ears, new graduate with no specialist qualification to their name, calling themselves a “Specialist” and performing your hip replacement, or dealing with you when you have a severe kidney infection, heart failure or perhaps cancer.  Matters are complicated further in veterinary medicine by the range of species that veterinary surgeons have to deal with.  Cows suffer their own particular set of medical and surgical problems as do sheep, horses, dogs, cats et cetera.  Each species is as unique as we humans are; our doctors have enough difficulty dealing with one species, let alone being asked to be “omnicompetent” in such a wide range of species.

Of course it is nonsense to actually think that any veterinary surgeon is truly omnicompetent at any stage in their career, certainly not on day one after qualification.  Veterinary surgeons specialise in a similar way to our colleagues in human medicine and surgery and obviously gain experience over time.  The first level of specialisation is usually to focus on a single species or small group of species (for example pet animal practice – often referred to as “small animal” practice).  Within this there is the potential for further specialisation just as there is in human work, including all the disciplines one might expect such as dermatology, cardiology, orthopaedic surgery and so on. 

In human medicine and surgery, of course, these specialists are easily recognised.  The National Health Service has a structured career programme so that if you are seeing a consultant in a given speciality you can be very confident of that consultant’s credentials.   Furthermore, if you are “referred” to someone by your GP, you can be absolutely confident that the referral is to a suitably qualified and expert individual.

Sadly, it is not so easy to recognise suitably qualified and expert specialist veterinary surgeons.  As a result of the principle of omnicompetence, absolutely any veterinary surgeon can claim to be an “expert” a “consultant” or a “specialist” with no constraints whatsoever.  There are no particular qualifications required for a veterinary surgeon to have before he or she can accept referrals from veterinary general practitioners in the same way that a specialist in human medicine or surgery will accept referrals from General Practitioners:  Absolutely any vet can do this, again under the auspices of “omnicompetence”.   

The only constraint in the UK is on the use by a veterinary surgeon of the term “RCVS Recognised Specialist”.  Individuals claiming to be “RCVS Recognised Specialists” must satisfy a number of stringent criteria, including qualification at the highest standards of examination in their speciality, demonstration of suitable experience by working for five years in their speciality before being recognised and undergoing ongoing re-accreditation to show that they are still truly expert in their field.  This all seems well and good, but would you be smart enough to spot the potentially very large difference between an “RCVS Recognised Specialist” and a veterinary surgeon who claims to be a “Specialist”?  The first has to have a proven level of experience and satisfy many stringent criteria that will give you quality assurance on the standard of specialist care that your animal receives.  The second might have nothing more than a basic veterinary degree and could have graduated only yesterday, but might conversely be a quite highly qualified Specialist like your own hospital consultant – you have no way of knowing from the title “specialist”.

What makes this even more difficult for the general public to comprehend is that there are various post-graduate qualifications that veterinary surgeons can achieve to demonstrate various levels of specialist competence below that of “RCVS Recognised Specialist” status.  The structure of these qualifications is so complex that they are not always fully understood within the profession itself, so there is little hope that members of the public will understand them!  The pdf Veterinary Qualifications is an extract from the RCVS website on this matter from 7th July 2011 – have a read of it and see if you can work out the difference in the different levels of specialisation. 

Are you confused yet?  You should be, but just in case you’re not there is an added layer of complication.  The RCVS offers “Diplomate” standard qualifications as the highest possible qualification that can be achieved by examination.  This qualification is one that entitles the individual to apply for “RCVS Recognised Specialist” status.  The number of these “RCVS Diplomas” is by no means comprehensive enough to cover all specialities and is in fact reducing as the years go by.  Furthermore, there is no requirement for re-accreditation in RCVS Diploma examinations, only for RCVS Recognised Specialist status.   In Europe there is a well established and comprehensive Diplomate system which you can read about here

These qualifications are recognised throughout Europe and the USA and they do have a re-accreditation requirement.  Individuals with this qualification have letters after their name prefixed by “DE” (for example DECVS = Diplomate of the European College of Veterinary Surgery, DECVIM = Diplomate of the European College of Veterinary Internal Medicine and so on).  Their American counterparts have the prefix “DA” in letters after their name (for example DACVS – Diplomate of the American College of Veterinary Surgery).  Interestingly, these European and American qualifications do not appear on the website of the RCVS and yet they are widely recognised around the planet and the RCVS itself recognises these qualifications as suitable eligibility for its own highest accolade of “RCVS Recognised Specialist”!

Just in case you are still able to follow this there is yet another layer of complexity.  The very first layer of postgraduate qualification offered by the RCVS is at the so-called “Certificate” level (For example, CertSAS = Certificate in Small Animal Surgery).  This was never intended by the RCVS to be used as a “specialist” qualification and on the attached pdf you can see the vast difference between the criteria for this qualification and that of a “Diploma” holder.  All the “Certificate” standard qualification indicates is that the holder has a minimum of two years experience and a degree of “competence” in a particular discipline.  Unfortunately, despite the intentions of the RCVS to not recognise the “Certificate” examination as a “Specialist” qualification,  individuals with a “Certificate” standard of qualification are able to advertise themselves as providing “Referral Services” and will label themselves as “Specialists” (though not, of course “RCVS Recognised Specialist”) because of the principle of being “omnicompetent”.  If they advertised themselves as “competent” rather than “Specialist” that might be more accurate, but perhaps less attractive to clients!
At Northwest Surgeons, we have “RCVS Recognised Specialists” in every discipline that we offer as a referral service and in our support services.  Our normal minimum entry level qualification for “Specialist” clinicians is a Diploma (RCVS, European or American) standard.  We have two Certificate holders working for us.  One is as surgeon in a team headed by two “RCVS Recognised Specialists” and he is training to sit his RCVS Diploma in surgery in the next year or two – Northwest Surgeons is one of only four private referral centres in the UK recognised by the RCVS to train surgeons to this standard.  The other is our Managing Director who also works in the team headed by two “RCVS recognised Specialists” and recognises that he is a dinosaur with a level of qualification that has been overtaken by the times!

As the body responsible for setting standards in the veterinary profession and the “watchdog” responsible for representing the interests of the animal owning public so far as the veterinary profession is concerned, you might be forgiven for thinking that the RCVS would be jumping up and down to have a clear and simple system for the public to recognise the level of training and expertise offered by anyone claiming to be a veterinary “specialist”.  You would think that transparency for the animal owning public would be top of their list, but that does not seem to be the case.  If you have found the above difficult to follow and think there should be a clearer system, perhaps you would like to directly ask the RCVS why the system is so unclear by contacting them from this page.  Maybe you can suggest that they read this blog for themselves.

And finally…

If you skipped to the last paragraph – this is it. If your general practice veterinary surgeon is suggesting referral for your pet to see a “Specialist” then you need to be savvy enough to ask a few questions about the specialist.  What are the letters after their name?  (Look for the “D” for Diploma (DSAS, DECVS, DACVS, DSAM, DECVIM, DACVIM et cetera) rather than the “Cert” (CertSAS, CertSAM et cetera) to be sure you are at the highest level of qualification.  If the individual has “RCVS Recognised Specialist” written after their name then so much the better.  Place no store whatsoever by any other accolade that the individual might claim such as “Specialist”, “Consultant” or “Expert” since none of these mean a thing.   Finally, you should be aware that more and more veterinary practices have internal “specialists” often not at the highest level of qualification and corporate financial pressures can dictate that clients are directed towards these rather than to perhaps better qualified people elsewhere.  Remember, this is your much loved pet and your money – it is your right to be referred to where you want to go (There is a separate blog on this) and if you want your pet looked after by someone with the best qualifications you should ask your vet to ensure that you are referred to a “Diplomate” or an “RCVS Recognised Specialist” and not just to any old specialist.

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