System not well understood or appreciated... - Veterinary Practice
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InFocus

System not well understood or appreciated…

Malcolm Ness argues that handling referrals is about much more than having ‘a bit of paper’

At the outset I should make it clear that I know Huw Peplow only a little and of his work I know even less. What follows must not be misconstrued as comment or criticism of this colleague or his work.

Gareth Cross highlights the RCVS advice regarding referrals, which is essentially that clients should be helped to make an informed choice about a referral clinician and this highlights the obvious, but not widely known or acknowledged responsibilities upon the referring vet who must ensure that the clinician he or she is about to recommend to the client is appropriately expert and experienced.

It is interesting to note that “behind” the official advice in the Guide, the RCVS is becoming rather more robust on this subject. For example, its advice to clients says, “Whilst any veterinary surgeon is free to accept referral cases most practices choose to refer where possible to colleagues who are Diplomates or RCVS Recognised Specialists in the knowledge that these colleagues are trained and qualified to an appropriate standard.”

Similarly, Practice Standards (PSS) rules state that, “Incoming referral cases must only be advertised to the public by a holder of suitable qualifications. Where no suitable qualification exists, evidence must be available of further training or experience.” – a reflection of the responsibility on referral clinicians not to over-sell or over-stretch themselves.

I have long believed that if all clients are properly informed then any vet should be able to cultivate a referral practice. However, the situation is not a simple one: how can we tell whether a referral clinician is competent or merely confident?

A member of the public needing someone to diagnose and treat an animal’s illness looks for a vet and people can recognise “real” vets by their membership of the RCVS; they need never fall into the hands of a plausible, though under-qualified pretender.

There exists a similar system to allow the recognition of appropriately trained referral clinicians but it is obvious, not least from Gareth’s article, that this is neither well understood nor properly appreciated by many practising vets. That is a shame because it is precisely those vets in primary care practice who have the responsibility of guiding their clients in the choice of an appropriate referral clinician.

Gareth chose to write disparagingly about clinical postgraduate qualifications, referring to them dismissively as “bits of paper” and implying worthlessness. In February, a group of practising vets, aspiring surgeons from across the UK and Europe, travelled to Switzerland where they endured many hours of written, oral and practical examinations.

The examination was conducted by a group of experienced, specialist, internationally renowned practising surgeons. Before presenting themselves for examination, each and every one of these candidates had completed a formal surgical residency training programme – three years dedicated exclusively to surgery; full-time, hands-on training under the personal direction of an experienced, specialist surgeon.

During their training programme each resident will have documented, in detail, several hundred surgical cases – some as primary surgeon, some as second surgeon, apprentice, if you like. Note well that during those three years each surgeon in training will have invested more hours in a single subject (small animal or large animal surgery) than any of us spent studying everything during our five years as veterinary undergraduates.

What’s more, before starting, each of these aspiring surgeons had several years experience and most already had a Certificate. To imply that a “bit of paper” is the only difference between these formally trained and exhaustively examined surgeons and the surgically enthusiastic “practitioner who does referrals” is misleading.

I have worked with, and know the work of, some extremely able surgeons with Certificate level qualifications and others with no post-nominals at all, but these individuals are remarkably few and far between. The importance of clinical specialist qualifications is the confidence that clients or referring vets can take from knowing that the surgeon with the “bit of paper”, including the clutch of new Diplomate surgeons emerging from the exams in Switzerland, have a level of knowledge, understanding and technical surgical ability that has been rigorously assessed by informed, experienced, internationally renowned experts and found to be good.

What’s more, the knowledge, understanding and ability of these surgeons is significantly higher than it was when they themselves were enthusiastic surgeons in practice or indeed when they sat and passed their own Certificate three or more years earlier.

Gareth’s piece does raise a couple of important points. Historically, it has been particularly difficult for an enthusiastic surgeon in private practice to progress through Certificate and Diploma to Specialist status. It is easy to make accusations of “protectionism” by the universities but that is not, and indeed never has been, the whole story.

Many practitioners have benefited enormously from help, support and encouragement given freely by university clinicians and with the expansion of private referral practice lots of opportunities exist today for the genuinely enthusiastic and motivated surgeon.

The “too busy to do a certificate” excuse is lame. Over the years I have had the pleasure of working for, working with, supervising or examining very many practising vets during certificate and diploma studies – these are not workaholic social cripples with no understanding of work-life balance and neither are they merely the beneficiaries of fickle good fortune.

They are instead, active busy practitioners, usually with a range of interests and often with young families who have taken the decision to pursue their surgical interest actively, conscientiously and methodically, then to subject themselves to peer or expert review by examination – confirmation that they are on the right line and that their efforts are not being wasted. The bit of paper is a bonus. As I pointed out at the start of this piece, I cannot possibly know enough about Huw Peplow’s surgery to pass useful or informed comment. However, I would suggest that neither does Gareth Cross and I am struck by the inconsistency that allows Gareth on one hand to enjoy the privilege afforded by his own bits of paper (BVSc, MRCVS) while being so disparaging of the efforts and achievements of others.

Gareth Cross responds:

I wrote the article as a practice profile and to flag up some issues which have been taken up by Mr Ness and Dr Viner, not as an opinion piece. I am disappointed that Mr Ness has misread the piece to be disparaging of Certificates and Diplomas. I have a huge amount of respect for people holding those and understand the level of work required to achieve them. I made it clear in the article that they were the benchmark of postgraduate achievement.

The piece was not meant to voice my (or Huw’s) opinion on the subject but to flag up a different way of doing things that is being successfully practised. Mr Ness quotes the phrase “bits of paper” to demonstrate what he perceives to be my “disparaging” attitude. I have re-read my article and cannot find that phrase anywhere. There is no hint of that and I do point out specifically that not completing or doing a further qualification is not “…a good thing” – i.e. it is better if you can do one.

And as Mr Ness points out, of course I understand the work needed to achieve a qualification, having done a BVSc. I am genuinely sorry that he has so badly misinterpreted my article. It was an objectively written piece to look at how practice is evolving and the different types of vets and practices that are out there, and the different qualifications and what people are doing with them.

Dr Viner seems to have taken it that way: as a discussion piece. When I wrote that “…the new certificates are widely perceived to be of a lower academic standard,” he correctly spots that that is my reporting of a widely-held belief and does not have anything to do with what I think myself.

Like the BBC, magazine articles are often reporting facts and opinion and are not editorial comment. I could write on racism, but that would not make me a racist. Similarly, I can write about someone without postgraduate qualifications doing hip replacements without that meaning I think it is a good thing or a bad thing. It’s just a thing that’s happening and I wrote about it.

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