Want to know the secret to a win-win-win relationship among you, your clients, and your local ER or specialist? It should come as a surprise to no one that clear, unambiguous communication, mutual respect, and a principled approach to achieving what’s best for each individual patient is the key to healthy relationships between referrings (most of you), ERs and specialists (fewer of you), and our clients. Because it’s what’s best for our patients, after all. It’s a no-brainer. Yet I find that some of the most egregious lapses in ethical conduct among veterinarians occur when patients require specialized services. Financial considerations and competition seem to exert an undue influence on our professional comportment in these cases. Some recent negative experiences along these lines have made me think more deeply about these issues and, ultimately, to write this frank column about how best to navigate the turbulent waters inherent to the primary-secondary-tertiary care system our profession has adopted. It’s about sanctionable professional ethics, to be sure, but it’s also about etiquette, which effectively revolves around treating others as we would like to be treated, with fairness and kindness above all. It’s only by adhering to these simple rules of the road that we’re able to provide the best care possible to our patients. This column is not about pointing fingers or putting anyone in their place. It comes from a place of finding solutions to a problem that threatens the referral system itself. To that end, here’s a short guide to the etiquette surrounding referral and referring relationships: [Note: At the risk of being pedantic, I’ve taken the liberty of including here the relevant sections from Principles of Veterinary Medical Ethics (PME) of the AVMA, where applicable.] Let’s all be clear on who’s a specialist From III. f. of the PME: “Only those veterinarians who have been certified by an AVMA-recognized veterinary specialty organization should refer to themselves as specialists.” Secondary care providers: If you haven’t been board certified you shouldn’t call yourself a specialist. Even if you limit your practice to dermatology, for example, you are not a specialist. You’re simply a veterinarian who limits her practice to dermatology. Calling yourself a specialist is misleading if you haven’t received the advanced training and certification. Primary care providers: Don’t refer to someone as a specialist unless they’ve earned it. For example, that surgeon who comes in to perform your tough procedures isn’t a specialist, she’s someone who limits her practice to surgery. You should always be clear that this person is not board certified when you employ these individuals. Trust me—your clients will assume they are, and it’s unethical to obfuscate. Referring clinic: Always offer records From VI. d. i. of the PME: “The referring veterinarian should provide the receiving veterinarian with all the appropriate information pertinent to the case before or at the time of the receiving veterinarian’s first contact with the patient or the client.” It’s not fair to the client or the specialists to withhold any information about the patient, regardless of how we may feel about their seeking care elsewhere. Specialists and ERs: Inform the referring clinic upon examination From VI. d. ii. of the PME: “When the referred patient has been examined, the receiving veterinarian should promptly inform the referring veterinarian. Information provided should include diagnosis, proposed treatment, and other recommendations.” Sadly, in my neck of the woods this only happens about 50 percent of the time. Even then, reports tend to lag a couple of days. The rest stumble in a long way after and some never arrive at all! Honestly, there’s no excuse, particularly for ER reports where my referrals are made blindly and are especially time sensitive. It makes me look as if I don’t care when my patients are hospitalized elsewhere. Moreover, it gives me no chance to weigh in on important decisions my clients may not realize I can help them with while their pets are hospitalized in the hands of others. Specialists and ERs: Inform the referring clinic upon discharge From VI. d. iii. of the PME: “Upon discharge of the patient, the receiving veterinarian should give the referring veterinarian a written report advising the referring veterinarian as to continuing care of the patient or termination of the case. A detailed and complete written report should follow as soon as possible.” I can’t tell you how often I’ve failed to receive reports that my patients have died or have been euthanized. This is an especially egregious lapse in communication; one that directly threatens my credibility as a primary care provider. And when it comes to the living: How am I supposed to keep a complete medical record of my patient without your reports? Referring clinic: You must offer emergency and overnight critical care elsewhere From VII. c. of the PME: “When veterinarians cannot be available to provide services, they should provide readily accessible information to assist clients in obtaining emergency services, consistent with the needs of the locality.” It’s unethical to fail to direct clients to an ER when they’re available and you’re not. It’s similarly unethical to fail to offer overnight care at an ER facility should you be unable to provide intensive care overnight to a client whose pet would be best served by continuous monitoring. Referring clinic: You must offer specialty-level care From VIII. d. of the PME: “Veterinarians who believe that they haven’t the experience or equipment to manage and treat certain emergencies in the best manner should advise the client that more qualified or specialized services are available elsewhere and offer to expedite referral to those services.” You’ve got to offer. Period. As this statement implies by including the word “specialized,” this also holds true for specialty services. It doesn’t matter that you perform cruciates and plating, too, or that you feel comfortable relying on your own ophthalmology, oncology, and internal medicine skills. You must offer a referral whenever it’s clear that a patient would benefit more from seeing a specialist. Indeed, it bears mentioning, at least in passing, that specialists are available to perform this function and that they may be able to perform it more competently, albeit typically more expensively. I don’t care how you couch it, but you have to offer it so clients can make an informed decision. That’s what you’d want your own GP or dentist to do, right? ERs and specialists: Don’t cannibalize your referring clinic’s business or step on our toes That means… a) Don’t perform generalist-type procedures if they can wait. (Don’t neuter my patients or extract teeth because “they’re already under,” and don’t slice into hematomas in the middle of the night. I promise, it won’t explode before you send the patient back.) b) Don’t perform general care-style follow-up or monitoring labwork. (Derms, I can do a T4, too. Oncs, I can run a CBC and take chest films. I could go on.) c) Don’t offer opinions on general care issues when they’re not relevant to the specialty service provided. (It galls me when my specialists comment on neutering or vaccinating my patients when it’s not relevant to their specialized care.) d) Don’t refer our patients to other specialty services, in-house or otherwise, without letting us know first. Remember, these are our patients we’ve entrusted to you for your services alone. We want the chance to offer all levels of care. Sure, I’m a general care practitioner and I have biases, too, which may be reflected above. I also make mistakes and get uppity with specialists and ER services when I should be offering solutions instead. But we would all do well to follow the rules our professional organizations have laid out if we’re to do best by our patients. Dr. Patty Khuly owns a small animal practice in Miami and is a passionate blogger at drpattykhuly.com. Columnists’ opinions do not necessarily reflect those of Veterinary Practice News.
