A COVERT philosophical “battle” is taking place in the United States over the future structure of small animal (pet) veterinary practice.
Most of the participants are unaware that a battle is going on because they are either part of the proud and paradigm-insulated group that is responsible for getting the profession to where it is today, or they have the silo perspective that marks a profession dominated by small, separate, and isolated work centers.
Nevertheless, I believe that we are at an important inflection point regarding the future structure of pet practice: will the dominant practice model be “general practice” embracing wellness care, preventive medicine, and sickness (reactive) care and supported by clinical specialty referral practices for rare and challenging cases, or, will the profession continue to adopt the human medicine practice model of providing expensive and inconvenient reactive care by a multitude of clinical specialists, with general practice relegated to providing routine health and sickness evaluations and triage services?
Proponents of the latter model are mainly clinical specialists who seem to equate quality medicine with sophisticated technologies and believe that two to four years of additional clinical training and experience (i.e. internships and residencies) and board certification are necessary in order to practise quality medicine.
This, of course, is the model followed by human medicine in the US. However, there is now widespread agreement that this reactive human medicine practice model, although capable of delivering daily miracles, is too expensive and inconvenient – and failing to provide the care wanted by broad segments of society.
In veterinary medicine, approximately one third of new graduates of US veterinary schools now apply for such clinical specialty track training programmes, believing that this is essential for success in veterinary practice.
As a result, specialty practices are being established in virtually every urban environment. General practices are being urged to refer cases to such practices, and many school clinical faculties now advocate such referrals as representing the new standard of care.
Senior veterinary students who rotate through clinical specialty clinics repeatedly hear that, “If you see a case like this, you should refer it to someone like me – a specialist!”
I suspect that the same battle is quietly changing the face of veterinary medicine in the UK and Europe, too. In this and future articles, I will illustrate through specific vignettes how the “battle” is being waged and the implications for practice.
It is important that we understand the current state at the macro level so that we, as general practitioners, have a chance to participate thoughtfully rather than be caught unaware after the battle is over! I hope that these comments generate some vigorous discussion!
Reactive practice
In the United States, human medical practice is essentially entirely reactive: practitioners have almost completely lost any role in wellness care and preventive medicine. Such services can now be obtained through pharmacies, large stores and, increasingly, via the internet.
Self-care is the dominant wellness model in the US and is extending its reach into reactive care through web-based systems and the ready availability of prescription drugs, vaccines, etc., through internet sites.
Similarly, food animal practice in the US has largely gone the same route as practitioners have persisted in playing reactive roles (being part of the problem) while farmers wanted preventive help in maintaining maximum health and productivity for their herds (i.e. preventing the problems from arising).
It is less obvious in the pet market, but there is a growing gap between what pet owners want for their pets (health, happiness, a strong and satisfying bond, and long life), and what veterinarians want and are trained to provide: sophisticated, reactive services (diagnosis, treatment).
It is easy to forget that the veterinary profession is a service profession and what clients want matters. They, through the marketplace, have a history of getting what they want.
An ethical dilemma?
A number of infectious diseases are currently sweeping across the US, driven by people movement, lack of geographical barriers, and perhaps by climate change and the migration of vectors. Examples include heartworm, West Nile virus, Lyme disease, anaplasmosis, ehrlichiosis, babesiosis, etc. In the future, it could include SARS, avian flu, monkey pox, leishmania, etc.
It seems that if an infectious disease is endemic anywhere, it can now become endemic everywhere! This presents us with an interesting ethical dilemma which depends upon whether one takes a micro (individual pet) view or a macro (pet population) view and how one answers the question, “When is it appropriate to initiate preventive treatments for infectious disease?”
Should one try to prevent a disease from becoming endemic in an area (e.g. Oregon) by initiating a vaccination programme (e.g. for West Nile virus), or should one wait for it to become endemic before it is justified in trying to prevent it?
The predominant opinion in the US, focused as we are on reactive medicine and the individual pet (member of the family), is that exposing it to unnecessary risk is viewed as unethical.
On the other hand, not working to prevent a serious disease from becoming endemic when the means (vaccine) are on hand surely must also be unethical, but only if one views the larger picture of population health which only secondarily affects the individual pet.
I have been aware of this ever since our practice was accused of being unethical because we recommended heartworm preventive treatment in our north-western region hospitals. Dogma had it that the disease did not occur in these states because the ambient temperature did not support the full development cycle of the parasite.
Fortunately, we had hospitals in most states and had been able to track the disease’s spread westward and northward into these states. This is a privilege that practitioners in single, stand-alone practices do not have. It allows us to see the big picture as well as understand the dynamics of disease spread.
It also raises our awareness of how important it is to our patients and clients for us to prevent disease rather than wait for it to arise and then treat it. It also raises the clear responsibility we have to share our knowledge with our colleagues in the veterinary profession.
Risk assessments
So, how does this tie in to the “battle” mentioned above? We have become aware that resistance to disease prevention measures predominantly comes from our clinical specialty colleagues who are oriented to reactive medicine by virtue of their clinical disciplines (problem first, solution second) and individual pet focus.
Because of their clinical expertise and reputations, they understandably dominate groups and panels making medical recommendations. In view of their orientation, they naturally advocate performing risk assessments for each pet prior to initiating preventive care (vaccination, heartworm prevention, etc.).
In cases where the disease in question is rare because it is not yet endemic, it is viewed as all risk and no benefit – and hence any preventive treatment would be untenable. As a result, advocating measures to prevent a disease from becoming endemic is viewed as quite unethical and constituting “malpractice” to some.
This view reflects their reactive, patient-centric perspective. General practices are more attuned to the need for preventive care of their patient population, but can be intimidated by these “practice standards-setting” groups.
Travel by both people and animals and the translocation of cultural practices are also starting to affect the animal disease spectrum in the USA and UK. We must guard against letting the move towards a focus on the needs of the individual pet get in the way of making sensible decisions to prevent the rise of new endemic diseases.
