Know When To Leave It To The Specialist

When trusting a specialist for care.

I’ve got this acquaintance. She’s an educated professional and a commonsensical kind of person. Unfortunately, none of this kept her from suffering a failed root canal at the hands of a general practitioner dentist. She trusted him and he failed.

Not only did he legitimately fail to provide a reasonable root canal, leading directly to an abscessed tooth that he never re-radiographed postprocedure. Where he most failed was in his duty to offer the services of an endodontist before performing the work.

That got me to thinking about all the cases I see as a “second opinion” and all the disaster cases my significant other, a vet surgeon, treats on the back end of poor general practitioner judgment calls.

Most of mine are cases that need not stop at another GP before heading directly to a specialist. That they land in my lap in the absence of a referring vet’s communication is testament that this “second opinion” was not recommended by their initial veterinarian.

Rather, it’s an outright defection that represents a dereliction of trust in their regular vet—all of which might have been prevented given a simple referral to the appropriate source: a specialist.

Don’t Hesitate

I hate these situations. I’m asked to explain why I refuse to treat the pet unless they understand that I am not the appropriate channel through which their frustrations or grievances should be directed. “Do not pass go,” I say. Head straight to the specialist.

It’s the draining tract in the cruciate repair. (It can happen to anyone, I know, though I’ve never seen one come from my specialists.) It’s the declaw gone bad. (I’ve seen more second-opinion onychectomy cases than I care to count.) And it’s the insulin-resistant DKAs who are on 10 units of Vetsulin 2 months postdiagnosis. (They  somehow survived.)

My e-vets have seen at least one of my spay dehiscences a year for the past 15 years I’ve been in practice, and I, too, have had more than one atypical Addisonian who deserved an internist over my blundering ministrations. We all make mistakes. But mostly it’s done in good faith. I think. I hope.

Price Sensitivity

But the obvious internally complex or surgically cumbersome cases? I won’t touch them. They go straight to the specialist, as all my patients do once it’s obvious they’ll be better served by others. That is, if my clients can afford them. I know the price differential as well as I understand the differences in quality of care. And these are the options I offer my clients.

Ultimately it’s our job to ensure that our clients have the benefit of full disclosure. As in, “Sure, I’m comfortable with that PU, complex Cushingoid, conjunctival flap or femur fracture, but you need to understand these are procedures fraught with complications. If you want to minimize these and happen to have the funds to do so, I’d urge you to consider that veterinary specialists have better tools to treat them. Don’t have the funds? I’m all yours.”

Now for the practical vet’s approach: What a surprise! It happens to mirror the pat-on-the-back practitioners’.

That’s because almost every one of the major lawsuits GP veterinarians have been up against in recent memory has been related to overreaching clinical behavior in the absence of a client’s informed decision. Why? Because we’ve failed to give them one. Here’s where I say: More power to the prosecution.

Sad Examples

I’ve seen:

  • Chemo protocols worthy of 1970s medicine.
  • Fracture repairs where a plate, modified KE or interlocking nails—not a pin—would have done the trick.
  • “Vet surgeons” who are uncertified hacks cutting backs without a myelogram.
  • Cherry eyes with glandectomies.
  • Peritonitic colonotomies that could’ve used an enema.
  • Elbow OCDs flanged wide open with nary a nod to modern standard operating procedures.

All of these might have gotten a pass if not for the lack of informed consent on the part of justifiably aggrieved owners now looking to the board or the courts for recourse.

As a profession, we should get with the program and move on. Accept your GP status and do it right. You’re not helping anyone, least of all your bottom line, by doing what you are not best trained to do. <HOME>

Patty Khuly, VMD, MBA, is a small-animal practitioner in Miami and a passionate blogger at She earned her veterinary degree in 1995 and her business degree from Wharton in 1997.

This article first appeared in the November 2009 issue of Veterinary Practice News

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