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Feature

So how do you become a veterinary specialist?

By admin On December 7, 2011 - 0 Comments

In past blogs we’ve discussed the subject of veterinary specialisation, including referral to a specialist and the future of veterinary specialisation. But how does a vet actually become a specialist?

We all know that training to become a vet takes 5-6 years, depending on which vet school you are fortunate enough to study at. Many students will decide whilst at vet school that they want to follow a specific career path, whilst some of us take a little longer to experience what life as a vet is like, before deciding where our interest lies. For determined, driven individuals the next step on the specialist pathway is either an internship, or a period in general practice, although with competition for specialist training positions becoming fiercer, an internship is seen by many as essential.

Interns are junior vets working in referral practices, where they rotate through different areas within the practice to gain a broad experience base. At this stage many interns will already have an idea of where their interest lies, be it surgery, medicine, anaesthesia or one of the other specialities that this varied profession can offer. The key to furthering an interest is experience and experience can only be gained over time and with a sufficient case load. This is the basis of specialist training programs, known as residencies.

A residency is a structured program over a set period of time, under the supervision of an existing specialist in a specific area of veterinary work, such as surgery or medicine. Most residencies are undertaken within a university, but more private specialist practices now offer this opportunity. Northwest Surgeons is the only private referral centre in the north of England to offer an RCVS approved residency in orthopaedics.

The intensive workload undertaken during a residency, which is typically over a 3 year period, is the foundation for achieving specialist status. Combined with this, a resident must conduct research and publish scientific papers to fulfil the requirements of their chosen diploma. Once these criteria are achieved then the resident is eligible to sit their diploma exam. The achievement of specialist status, whether European specialist or RCVS specialist, assures that the vet you are seeing is of the highest calibre. But it doesn’t stop there. For continued assurance specialists must continue to work hard to maintain their status and ensure they keep up to date. Every 5 years we undergo a revalidation where we must prove that we actively contribute to the veterinary profession.

At Northwest Surgeons we offer specialist services in surgery (soft tissue, orthopaedics & spinal surgery), medicine, cardiology, anaesthesia & pain management and diagnostic imaging. Each service is led by either an RCVS or European Specialist which allows us to offer you the very best for your pet.

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physiopic
Feature, General

Spinal surgery: it’s all about the aftercare

By admin On November 22, 2011 - 0 Comments

Dogs with spinal problems form a large part of our specialist orthopaedic case load, with intervertebral disc disease high on the list. Spinal surgery is complex and requires a high level of surgical experience to perform. But that’s only half the story. Following surgery aftercare is of paramount importance and these dogs really benefit from physiotherapy. Here we give you an idea of the rehabilitation techniques used by the nursing team at North West Surgeons.

The spinal cases we see at NWS are predominantly dogs so the focus of this blog is canine physiotherapy and the rehabilitation of dogs following spinal disorder. The spinal cord (in humans and dogs) transmits information from the brain to the rest of the body. The cord is soft and easily damaged. Spinal injuries, disorders and disease can often cause compression of the cord which results in a failure of this transmission of information between the brain and the rest of the body. (There are other reasons a cord can become damaged). Most commonly, the patients we see have lost movement, strength and coordination of one or more limbs as well as the loss of bladder and/or bowel control. Some are unable to walk or stand on their own, some have weak, flaccid muscles while others have tense muscles and rigid limbs. Often the animal can be in a lot of pain, they may be stressed and are sometimes frightened. Pain control is paramount and these cases will be under the care of our specialist anaesthetist as part of the rehabilitation team.

Once a diagnosis and treatment plan has been made by one of our specialist veterinary surgeons the patient is passed on to the nursing team to implement their care. One of the elements of spinal patient care is physiotherapy and rehabilitation which we aim to perform 2- 3 times a day, more often if necessary. Hospitalised spinal patients: During the initial stages (this can be anything from 1- 2 days and up to 2 weeks depending on the level of damage to the cord) we aim to;

  provide muscle relaxation and stimulation

  prevent muscle atrophy (wastage) and further injury

  maintain joint flexibility and muscle mass with a long term goal of improving muscle tone 

  improve sensory awareness and use of the limbs so the patient can stand and walk with minimal assistance. Once this is achieved we can think about discharging the dog home.

Rehabilitation and Physiotherapy -What we do:

Each session aims to provide the patient with mental and physical stimulation so they have to be fun and rewarding for the dog. We use plenty of verbal praise, treats and toys to encourage them. Regardless of the stage the patient is at in terms of progress each session starts with massage techniques, then we focus on maintaining the range of motion in each joint of the affected limb (or limbs) followed by stimulating and re-educating affected muscles then stretches of each major muscle group.

For our massage we use stroking and kneading techniques as both are easy to perform and easily tolerated by animals. Ideally each session should finish with massage. As the patients begin to progress to standing or walking by themselves we can then add in more advanced exercises to improve muscle strength and balance. The activities used to improve their coordination, strength and balance can be physically tiring so are carried out little and often throughout the day with plenty of rest periods in between.

 Why do we use massage?

 To promote mental and physical relaxation of the patient.

 To increase blood flow to the muscles being massaged. This will help improve oxygen supply to those muscles and remove any metabolic waste products which if left to build up can cause muscles to ache (like the day after a strenuous work out!)

 To warm up the muscles before we can stretch them

 To help stimulate endogenous endorphin release (natural pain relief) When do we use massage?

  At the beginning and end of each session and always before and after further movements and stretches as it prepares the patient for further tissue manipulation

  Massage can be relaxing or stimulating depending on the techniques used so is useful when a patient has too much or too little muscle tone; ie tense rigid limbs or floppy weak limbs. The muscle tension or spasms can be secondary to their spinal condition or can be if they are frightened/ uncomfortable. Deep massage can help relax these patients.

To prevent muscle atrophy (wastage) and maintain joint flexibility and muscle we perform passive range of motion exercises (PROM) followed by stretches. During PROM the handler gently flexes and extends individual joints over several seconds as far as it will comfortably go through its natural range. PROM exercises can be performed with the dog either lying down or standing up, if the limbs are weak and floppy we assist the patient to stand to perform PROM and if the limbs are tense and rigid then we perform PROM with the patient lying down.

Why do we use PROM and stretches?

 to help maintain or improve joint mobility

 to help prevent muscles becoming stiff and being at risk of contracture

 to help improve neuromuscular awareness and function

 to mimic the sensation of walking by encouraging the foot pads to come into with the ground (or your hand if done lying down)

It is important to get the spinal cases up and about on their feet as early as possible, If they are unable to walk they area assisted by the handler using a sling (or hoist in larger dogs) to take the dogs’ weight. This can require up to 3 people depending on the size and mobility status of the patient. The purpose of assisted standing is to encourage nerve and muscle function, re-educate muscles, develop strength and enhance proprioception (knowing where their feet are), not forgetting mental well being – often being stood up and taken outside and encouraged to interact with our nursing staff can lift a dog’s spirits. Often spinal cases can be hospitalised for a couple of weeks so access to outside, daily routine and interaction with staff is really important to stop them becoming bored or depressed. Each day we try to get the patient standing for a little bit longer, maybe starting with 5 minutes 2-3 times daily building up to 5 minutes 3-4 times daily and increasing to 6 minutes 3-4 times daily etc.

 How: The feet are correctly positioned on the ground and their bodyweight supported (but not taking all bodyweight) with a sling. The amount of bodyweight we are taking is gently reduced to allow the dog to take as much of their weight as they can. We start by letting them take their weight for a few seconds then support them again. Gradually the amount of time they are taking their own weight is increased. Some dogs are able to hold enough of their own bodyweight to allow the handler to perform PROM with a second handler providing sling support.

Progression from assisted standing to the dog beginning to walk for themselves can be a slow but steady process. Once the dog shows signs of voluntary movement in their limbs (ie the messages are getting from their brain to leg muscles to tell them to walk) we can begin to encourage assisted walking, this is similar to assisted standing in that a handler uses a sling or hoist to take some of the dogs body weight but the dog is encouraged to slowly take “baby steps”. The dogs need plenty of encouragement and praise as this can be a very tiring process and they need to know they are doing a good job! It is not unusual for our kennels staff to stand at one end of the corridor with squeaky toys and treats encouraging a spinal case to walk towards them and then getting very excited by the efforts made by that spinal dog in re-learning to walk. What about at home? It is usually at the point that a dog can walk with minimal assistance and has some (or full) bladder and bowel control that we can think about getting them back home to their owners. Often the dogs will still need some assistance when walking and a continuation of rehabilitation exercises at home but this is something that can easily be taught to owners.

 How long will recovery take? Full recovery can take 4 to 6 months, but most dogs are walking again (albeit in a wobbly fashion) within 4 weeks. Dogs that are more severely affected to begin with, or those that have been affected for longer before treatment, are often slower to recover.

You can see that care of the spinal patient really is a team approach and the reward of seeing a paralysed dog walk again is immense.

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General

Dressings – The dos and don’ts

By admin On October 28, 2011 - 0 Comments

If your dog or cat is lame, and you get referred to Northwest Surgeons, you are likely to see one of the orthopaedic team. Some lame patients have fractures or ligament damage and have a dressing placed by the referring vet for support. Some cases may have damage to the skin and tendons in the leg, and a dressing is applied to cover and protect these. In the management of wounds at Northwest Surgeons your pet can benefit from the expertise of our soft tissue surgery specialist Catherine Sturgeon. Equally some of the cases seen at Northwest Surgeons require management by the placement of a dressing and may be sent home from the hospital with a dressing in place to protect the skin, soft tissues or healing bones.

Having seen some complications recently, we felt that some general advice on dressings may be of use. Many of the complications seen are avoidable.

• It is always worthwhile considering that a complication with a dressing, however trivial it may seem, is worth reporting as some complications can develop into limb-threatening problems.

• If a dressing is properly applied then the patient should be comfortable. We feel that a dressing should be well tolerated if it is comfortable. If your dog or cat is chewing or licking the dressing, this should raise doubts about the comfort. If the dressing is uncomfortable it may be putting pressure in areas it shouldn’t and complications can arise.

DOS

• Contact a vet you have any concerns.

• Keep the dressing dry. This can be achieved by applying a plastic bag or specially designed boot (which can be ordered from a vets or on-line) over the dressing to stop it get wet when walking on damp ground.

• Monitor the dressing for signs of the dressing slipping. The dressing will slip down the leg so watch the toes (if they are visible) and if you can no longer see them then the dressing is likely to have slipped. Also look at the top of the dressing, is it possible to see part of the leg which you couldn’t originally?

• Monitor for swelling. This is often seen in the toes, if they are visible, but can also be seen at the top of the leg.

• Monitor the dressing for abnormal smells. This could indicate a problem and the dressing probably will require changing.

DON’TS

• Ignore your pet if they start to chew at the dressing. If the dog or cat seems to be paying more attention to the dressing than normal then it probably is uncomfortable and needs to be changed.

• Allow the dressing to get wet and not seek veterinary attention. The foot can become damp and start to fester if left unattended.

• Leave the plastic cover in place after the animal has been outside as the foot can become sweaty and damp.

• Ignore any abnormal smells.

• Ignore a dressing if it has slipped.

Once a dressing has been applied and an animal is sent home with the dressing in place, we, as vets, can no longer control what happens to the dressing. It is therefore requires excellent ownership to carefully monitor and protect a dressing. But between the team at Northwest Surgeons and your own vet, we are here to help. Northwest Surgeons is staffed 24-7 by a Veterinary Surgeon so there is always advice at hand.

As vets we would much rather be contacted about a problem and find out it is a minor concern and nothing to worry about, rather than seeing a dog or cat where a dressing problem had arisen, nothing was done initially, and the problem becomes major and we find nothing more can be done to save the limb. Luckily, these cases are rare but they do happen and we all need to be aware of the potential risks.

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General

The future of veterinary specialisation – have your say now!

By admin On October 13, 2011 - 0 Comments

We have previously written detailed blogs on the complicated and unclear nature of specialisation and referral procedures in veterinary practice

11th August 2011:  Is my veterinary specialist a proper specialist?   

26th August 2011:  Referral to a Specialist: Your freedom to choose (Provided you ask the right questions). 

We strongly believe that the system of veterinary specialisation is currently unfair to the animal owning public and that it does not ensure that animal owners are always given the best options for care of their much loved pet.  Pet owners need a system that is transparent and robust to ensure that they are always given the best possible advice when referral to a specialist is indicated.  The public must also have absolute confidence in the qualification and re-accreditation of any veterinary surgeon they are seeing, especially those claiming “Specialist” status.  At present this is not the case:  The problem is a complex can of worms and if you have the time you might want to read the previous blogs to understand why.
There is, however, a glimmer of light on the horizon.  The Royal College of Veterinary Surgeons (RCVS) is the body that governs the veterinary profession in the UK and which is charged with acting in the interests of the animals and the public, not the interests of the profession.  A Working Party of the RCVS has reported on the issue of specialisation in the profession and has produced a public consultation paper (which you can read HERE).  This report is independent of any vested commercial interest in veterinary practice and it very much endorses our view of the current problems.  The report goes on to propose very significant changes to the organisation of specialisation in the profession which, if adopted by the RCVS, should go some considerable way to improving matters for animal owners and animals in the UK.  

Northwest Surgeons completely supports the findings of this Working Party and we are keen to see the findings of the report enshrined in our Professional Code of Conduct.  There is no guarantee that the findings of the report will be adopted in full or in part by the RCVS.  The report must go before the Council of the RCVS and it is the Council that will decide which (if any) parts of the report are adopted. By its very remit, the council must take both veterinary and public opinion into consideration when making its decisions, but should put the public needs first.  However, The Council is a large body with over 40 representatives on it with very diverse opinions, not all of which will be in favour of clarifying matters for the public in the way that the Working Party has proposed.  It is therefore very important that you have your say if you care about the quality of the specialist that may be looking after your animal in the future.  It is unlikely that another Working Party would be convened on this subject for many years.
You might also want to visit www.rcvs.org.uk to read the RCVS view.
On page 25 of the consultation document there is a list of 10 questions for consultation.  Please take the time to read the document and to report back to the working party by answering the questions on page 25, explaining in your reply that you are a member of the animal owning public. 

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dontthrow
Feature

Think before you throw that stick!

By admin On October 7, 2011 - 0 Comments

For many dog owners, the longer summer evenings mean a chance to enjoy some of the beautiful countryside of the North West with their pet. Inevitably for many people, the temptation to throw that stick your dog lovingly drops at your feet during the walk is just too much to resist. What could the harm be? Unfortunately, that innocent game of fetch could turn in to a painful injury for your pet and an expensive trip to see the vet.

Every summer we see a number of dogs who have a penetrating injury of the delicate tissues at the back of the mouth after jumping to catch a stick. Sticks can travel long distances in the tissues of the neck and pieces of stick will sometimes end up as far down as the chest cavity. It is impossible to know when the stick is removed by the owner whether any pieces have been left behind. In addition these dogs can also have painful injuries to the back of the throat, oesophagus or windpipe. We also see dogs that have developed an abscess in the tissues of their neck due to the pieces of stick which can be left behind after a penetrating injury. This can happen up to several months after the initial injury.

Treatment of stick injuries often requires camera examination of the oesophagus and windpipe and advanced imaging such as a 3D x-ray scan (computed tomography) or an MRI scan to try and identify where the soft tissue damage is and also the location of any pieces of stick which have broken off as the stick is pulled out. Attempting to find pieces of stick without the help of such scans can be very difficult and involves large scale dissection of the soft tissues of the neck. It is a little bit like attempting a road trip in the middle of the countryside with no map and no satellite navigation. This therefore increases the risk that pieces of stick will get left behind leading to the development of further abscesses.

Surgery also means navigating some very important and delicate structures such as nerves, blood vessels and the windpipe. In some cases, opening and exploration of the chest cavity can be required to ensure all the pieces of stick are removed. Luckily here at NorthWest Surgeons we have access to the specialist scanners and cameras we need to help these dogs and our soft tissue surgeon Catherine Sturgeon is experienced in dealing with these tricky cases. However, it is important to remember that even with the expertise of a specialist surgeon and specialist scans, it is difficult to give an owner a cast iron guarantee that all foreign material has been removed. It is therefore much better to avoid the risk in the first place so why not treat your dog to a new toy!

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blood cells
Feature, General

Do dogs and cats get DVT?

By admin On September 22, 2011 - 0 Comments

A deep vein thrombosis (DVT) is a blood clot that develops in the veins deep within the body, partially or totally blocking blood flow. In human patients this is most likely to occur in the veins within the muscles of the calf and thigh although it will occasionally form in other veins. We presume that the situation is similar in our pet patients.

Deep vein thrombosis forms part of a complex called venous thromboembolism. Venous relates to those vessels that return blood to the heart. A thrombus is a blood clot and an embolus is a part of a clot that breaks off and lodges in another vessel. When a clot lodges in a large vein supplying the lungs this is called a pulmonary thromboembolus (PTE).

Thrombi form in veins for many reasons; however these fall broadly into three categories: changes in blood flow, changes in blood composition, or changes in the vessel wall. Therefore situations which alter any of these three things will predispose to the formation of blood clots and the potential for PTE. Blood usually flows rapidly through veins aided by movement of the legs. A patient that is immobile for a long period of time eg: during a surgical operation or due to illness is at risk of clot formation. Long distance air travel in people is a well known risk factor. High blood pressure will also alter blood flow increasing the risk of clots forming. Changes to the vessel wall happen when the lining becomes inflamed. This can happen during surgery or in serious illness such as sepsis when a vasculitis may develop. Other damaging events include the need for repeated catheterisation, eg: if a patient requires intravenous fluid therapy or from certain drugs.

Changes to the blood itself that result in clotting are usually due to alterations in blood proteins that prevent inappropriate clots developing. With all body systems there is a delicate balance between providing a protective defence but avoiding an inappropriate reaction that may itself cause damage. Diseases that cause excessive loss of protein such as some kidney diseases and some gastrointestinal disease are termed prothrombotic. Some hormonal conditions such as hyperadrenocorticism (Cushing’s disease) can also alter components of the clotting system and combined with their hypertensive effects can result in increased probability of blood clot formation. Any patient with hypertension as part of their illness such as kidney patients, heart patients and diabetics may need observation for clot formation when hospitilised and checking of blood pressure.

 DVT can go undetected if the thrombus does not result in complete blockage of the vessel. However, if a piece of thrombus breaks off and forms an embolus which passes through the veins and heart to the lungs symptoms may be serious. These range from mild to severe breathing problems and in a few cases sudden death. It is estimated that 1 in 10 people with an undiagnosed DVT will develop a clot large enough to be at risk of serious PTE. Fortunately our understanding of the reasons for clot formation allows us to take certain measures to help prevent it in our veterinary patients. These include making sure animals get up and about as soon as possible after surgery. This is done by providing appropriate pain relief, but in those animals whose operations make walking difficult our nurses ensure the patient is turned frequently, receives appropriate cage side physiotherapy and when ready receives assistance in exercising such as supported walking and use of an exercise ball.

 In sick medical patients with known predisposing factors for clotting are identified we can provide anticoagulant medication such as heparin and low molecular weight heparin to ‘thin the blood’ and stop a clot developing. Patients with hypertension can have this treated with various medications. If a pulmonary embolus does develop patients are given oxygen therapy. Unfortunately we do not yet have veterinary emergency anti-clot drugs like those used in human medicine eg streptolysin because of both expense and poor patient outcomes where they have been used historically. We therefore put lots of effort into identifying pet patients at risk of clotting and thinking of the best patient plan to minimise the risk of this.

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Elliott
Feature, Our Pets

Would you ever think that your pet could save a life?

By admin On September 9, 2011 - 0 Comments

Well, thats what my cat Elliot has done……by giving blood! Many of us are blood donors ourselves and realise how important and precious that unit of blood is – but did you know that in the veterinary world we rely on blood donors too?

Just like in human medicine, when we need blood for a dog we can obtain it from a blood bank. The Pet Blood Bank is a not for profit charity and blood is provided by donor dogs. Cats however are a different story. Obviously most cats will not simply sit still to have blood collected which means there are no blood banking facilities for cats. If we need blood for a sick cat we rely on donors belonging to our staff, which is where Elliot and Fred get called in.

Cats have 2 major blood groups A and B and a smaller, less common group AB. They have preformed antibodies to the other blood types therefore they must be blood typed prior to the first transfusion. If blood typing is not carried out there is a risk of serious transfusion reaction. The blood types varies geographically and on breed. Siamese and other oriental breeds are mostly type A, whereas British Shorthairs, Persians and Maine Coons may be up to 50% type B. There is said to be only a small number of Domestic Shorthairs (moggies) to be type B in our region (which includes Fred!) Donors cats need to be healthy, fully vaccinated and weigh between 4.5-7kg. Ideally they should be kept indoors however this is rarely the case. So, prior to donation they should be tested for FIV (feline aids) and FeLV (feline leukaemia) because both of these diseases can be transmitted in blood products.

A small blood sample from Elliot was needed to perform the blood type, which was carried out at Northwest Surgeons. Elliot is blood type A and luckily enough we have Fred who is blood type B. Often we will ask owners of cats requiring a transfusion to bring their other cat in for testing. Both Elliot and Fred have given blood in the last year and saved lives. Instead of a biscuit and a cup of tea we offer our cats a free bag of their favourite food!

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Upton Sinclair
General

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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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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Superbugs in dogs and cats

By admin On July 19, 2011 - 0 Comments

“In 1942 a 33 year old woman lay dying of streptococcal sepsis in a New Haven, Connecticut hospital and despite the best efforts of contemporary medical science, her doctors could not eradicate her bloodstream infection.  Then they managed to obtain a small amount of a newly discovered substance called penicillin, which they cautiously injected into her.  After repeated doses, her bloodstream was cleared of streptococci, she made a full recovery and went on to live to the age of 90.  In 2008, sixty six years after her startling recovery a 70 year old man lie in a hospital in San Francisco with an endocarditis cause by vancomycin-resistant Enterococcus faecium (VRE).   Despite the administration, for many days, of the best antibiotics available for combating VRE, physicians were unable to sterilise the patient’s blood and he died, still bacteraemic”.

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