When should you refer a surgical patient?

10 guidelines to help vets know when to make the decision to refer their patients

By Phil Zeitzman, DVM, DACVS, CVJ

From a legal standpoint, any licensed veterinarian can perform any surgery on any patient. But just because you can doesn’t mean that you should.

So how do you know when to refer? How do you know which patient you can handle and which one you should refer? What if there is no surgeon within hours of your practice? How do you balance keeping income at your practice, the patient’s needs, and the client’s convenience and finances, all while keeping both hungry lawyers and your friendly state board out of your hair?

These 10 guidelines can help you when making decisions about a controversial, sensitive, and diplomatically delicate situation: the surgical patient referral.

Be realistic

Let’s get the most sensitive subject out of the way—honesty. Be honest with yourself and your clients about your abilities and experience. Trust your gut. Refer if you have a feeling you should. If a procedure is on the fringe of what you feel comfortable doing, let your clients know that. If you’ve never performed a certain procedure before, tell your client upfront. If your facility and your team will have difficulty performing the procedure and especially providing the aftercare, make your client aware. Put your patients before your ego.

Know your options

Get to know the specialists in your area. Obtain a list of services provided and modalities offered. Encourage feedback from your clients to gain their perspective on the referral practice, the specialist in question, and the staff. This will help refine your future recommendations.

Refer sooner

If you face a questionable situation, erring on the side of caution will help you sleep with a clean conscience. Both the specialist and the client will thank you. Referring earlier provides the patient with options that may become unavailable if the condition progresses beyond a certain point. It also covers you legally. It’s just about impossible to refer too early, but patients are referred too late constantly. Delaying a referral rarely benefits your patient.

Work them up

Perform preliminary diagnostics before your refer. This gives both owner and specialist a better idea of your patient’s health. So work them up. Perform blood work. Take thoracic radiographs in cancer patients (three views, of course).

Realistically, there’s no reason to refer a patient with osteosarcoma of the proximal humerus if the lungs are full of metastases. Knowing this before the referral saves the client and everyone involved a lot of time and aggravation.

Transfer for overnight care

Let’s say you performed a splenectomy. If you don’t offer overnight care, rather than sending her home that day, consider referring the patient to a 24-hour facility. She will be pampered overnight; she will remain on IV fluids, antibiotics and pain medications; and she can be checked for ventricular premature contractions. Then, if you like, she can be returned to you in the morning. This is far better than crossing your fingers that her IV line won’t kink or she got her e-collar off while spending the night at your clinic.

Approve clients’ requests

Never argue when a client asks about a referral. The worst-case scenario is that you will lose a little bit of money—a small fraction of your yearly income. The best-case scenario is that the specialist agrees with your diagnosis and treatment. Either way, you look like a rock star to your client, and you are covered liability-wise.

End-of-life decisions

Explore all options to help with end-of-life decisions. 
If euthanasia is on the table but the owners aren’t ready despite your recommendations, a referral can provide a different perspective. Euthanasia may still be the appropriate choice, but a referral can give your owners additional peace of mind in making the absolute most difficult decision.

Dr. Phil Zeltzman is a board-certified veterinary surgeon and author. His traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. Visit his websites at DrPhilZeltzman.com and VeterinariansInParadise.com.

AJ Debiasse, a technician in Stroudsburg, Pa., contributed to this article.

 

Quick referral tips

  1. Know what medications will interfere with the specialist’s treatment. For example, giving steroids will prevent giving certain chemotherapy drugs to treat lymphoma.
  2. Don’t give an NSAID when the surgeon is likely to use steroids (e.g., with upper airway surgery). Don’t give aspirin to a surgical patient. If in doubt, simply ask the specialist.
  3. Don’t give steroids when the surgeon is likely to use an NSAID (e.g., with orthopedic surgery).
  4. Don’t guess on costs. Tell a staff member to call the referral center for an idea of the cost clients will incur before referring them. There’s no need to waste anybody’s time if a client is unable to afford treatment or won’t qualify for third-party payment.
  5. Send relevant medical information to the referral hospital, including recent exam notes, lab test results, and radiographs. However, few specialists care about 10 years’ worth of vaccination history.
  6. Populate a referral form (if the specialist makes it available) to summarize the pertinent information about the client and the patient.
  7. Remind your client to fast their dog, and provide other basic information (such a web site, a brochure, and directions).
  8. Don’t tell a client that a treatment solution doesn’t exist until you run the situation by a specialist.
  9. Don’t allow small masses to become large—or giant—masses before referring for excision. There is never a situation where that can benefit the patient.
  10. Send updates—good or bad—to the specialist. Survival times are especially informative and educational in cancer patients.
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