1 Dec 2015
Nick Bacon
Job Title
Imagine a dog’s owners have a problem with their beloved Ranger. This could be a long-standing medical issue that’s just not improving or a mass they recently found that’s giving them sleepless nights because they lost their last dog to cancer and this looks similar.
Imagine the owners investigate online who the most experienced person is to deal with that problem, reads reviews from previous owners as if it was Amazon or Yelp, prints out research papers and conference proceedings, calls and speaks to their chosen specialist, or sends them an email.
The owners inform their family vet what they are doing and tell him or her to forward their details to the specialist for review. There is almost never a referral letter – at best perhaps a faxed copy of the medical record, and the owners take Ranger to the specialist the following week.
At the end, the owners pay for the treatment in full with cash or credit card, or take out a dedicated veterinary health care loan (after all, who insures their pets?), and walk away happy they have done the best they can for their family member. They return to the original family vet, or one that has superceded them, for aftercare or follow-up visits.
Is this private veterinary health care in the online era – where the owners pay the bills out of their own pocket and so feel empowered to explore their options and act independently for the good of their family member? They will take their pet to whoever they think represents the best value for money – their money.
Many owners will ask their family veterinary surgeon for guidance and assistance in this process, but it is by no means a necessity. This referral system already exists – and will be familiar to anyone who has worked in, or owned a pet in North America. This is an environment I worked in for a decade where talking to owners directly before referral, although not actively encouraged, was part of every day life.
In the US, the public are being encouraged to take ownership of their own personal health care, to ask their doctor if Lipitor is right for them, to self-refer to the dermatologist or orthopaedic surgeon on the back of the in-flight magazine.
So why should their pets, their fur-babies, their four-legged children, be any different?
What role is the family veterinary surgeon playing in this system along with the owner and the referral centre?
Where is the supportive three-way dynamic in this emotional environment – the delicate balance of multiple stake-holders who all ultimately have the same goal of improved patient welfare?
How would your relationship change with your clients if you knew they could independently refer themselves for a second opinion and you might be the last to know?
As a referral provider, how does that change how I behave knowing I too could be supplanted by the flavour of the month?
How do the referral centre and primary care vet build a strong relationship when the dynamic might be unbalanced from the outset?
This is a system built within the ultimate consumer society where the pet owner is the client, and the client is always right – but at what cost?
The owners may be able to act independently – they don’t need to ask to be referred or even to wait for the family vet to mention it – but they risk alienating their existing support network.
In the owners’ mind, however, if they feel Ranger is not the vet’s number one priority, they are going somewhere where he is.
Strong partnerships between referring practices and referral institutions develop in spite of this background not because of it. They grow through the core principles of open, honest communication, clear feedback and supreme professionalism.
It is very clear in the US system who the ultimate client is, but in the UK the client is equally the pet owner and the referring practice. There needs to be a healthy business to business relationship where there is emotional buy-in at each end, with understanding of individual and mutual problems.
A referral unit is essentially a concentration of specially, and specialty, trained staff with access to, and the ability to use, advanced equipment in the daily routine of their job. As such this should be seen as an asset since it makes this expertise available to a great number of practices without the capital investment in equipment and, more importantly, training and experience.
The rapid growth of CT scanners in the veterinary profession is an example of where training trumps the equipment. On one hand this revolution might result in advanced diagnostics and health screening for our national pets, but at the same time a CT scan will only accurately answer the question asked of it. Suspending clinical experience and acumen, and using a CT to find an answer to then generate the question is rarely the superior approach. Asking experienced colleagues to guide diagnostics, in full knowledge the case may never be referred, is a vital service that should be willingly provided by referral centres, and is key to the standards of our profession.
The referral relationship is, however, very complex as the two business entities are essentially different – complicated further because there are several versions of a referral model:
Problems develop as this is an unregulated business where there is a varying amount of respect between units muddied by the fact anyone can do anything. So where does that leave the primary care clinician?
For a long time the only option was university referral, combined with the fact owners had little to no ability to investigate their own pet’s medical condition and learn what else was available. Dr Google has changed all that. Owner-driven referral is moving forward at high speed, and this is inevitably changing the referral dynamic.
Clients expect their primary care clinician to make choices that are in the best interests of the animal, but if the owner is aware of options that are not presented to them, this may fuel a culture of self-referral or referral by request. Any perceived lack of transparency in this ever transparent and open world may cause the client to question the integrity of the veterinary referral process, and incline owners to demand a more US-style independence. After all, who is the client and who pays the bill?
However, all this willingness to refer is countered by barriers to the ideal referral, and these can be categorised as:
This might be because the primary practice feels it could perform the diagnostics or treatment equally well in-house, or alternatively concern about sending the case to a local referral unit that also offers first opinion work, for fear of losing the client completely. This obstacle is often cited, but may be the most nebulous, and also most controversial because it challenges the veterinary surgeon’s clinical confidence, competence and integrity within a care-based industry.
Kate added: “We make decisions based on the patients, not on finances – maybe that’s naïve from a business point of view, but it feels the right thing to do.” Peggy agreed, stating her last practice owner Jonathon regularly used a local hybrid referral practice just outside London, but was confident enough in his own business it didn’t concern him.
Where there is sensitivity on the clinical side about information being given to an owner, or treatment to a pet, which may not turn out to be correct when exposed to a higher level of clinical scrutiny. This may erode trust between family practice and owner and between referrer and the centre receiving referrals.
In a nutshell Kate summarised: “Vets don’t want to look stupid in front of the owner, and they don’t want to look stupid in front of the referral vet.”
Interestingly, both Kate and Peggy had little concern about the former, with Kate saying she would assume professionalism from the referrer and, of course, professional respect and courtesy was reciprocated. Peggy commented that she would be more concerned about owner perception as a new graduate, but she is confident enough in her own skills and experience that she is not afraid to tell the owner she doesn’t know. Peggy’s insight caused me to reflect on my own time in general practice as a new graduate working equidistant from Bristol and Cambridge vet schools. If I was certain of the diagnosis, but could not deliver the treatment, I would refer to my alma mater, Cambridge, because I knew the clinicians, who to refer to, and understood the process. If I had no idea what was wrong, I would refer to Bristol. As I now reflect on the other side of that equation, I realise such unpredictable behaviour is almost impossible to plan for or predict. Trust involves passing cases back when it is in the best interests of the owner and patient – discussing rather than instructing and creating forums to encourage mutual benefit and development.
Where two busy businesses do a good job for the patient, but fail to communicate properly. With increasing competition in the referral market, Kate commented: “Communication is really important and you get used to it being good.” Peggy admitted having stopped sending cases to a large referral centre because of poor communication when referral letters were being sent one to two weeks after the pets came home. A good friend of mine once commented that all he cared about for referrals was being “available, affable, and able”. This is a message not lost on Kate who said: “They could be the best person in the world, but if my client can’t see them for two months, I’m sending them somewhere else.”
Peggy expects no more than a two-week wait for her clients, or she will look for another referral solution, elaborating for cancer cases, she would expect a shorter wait than that. The availability is not just about receiving a case, but also being able to pick up the telephone for a conversation. This is equally important for mutual recognition of each business’ contribution to the relationship, and helps the referral practice understand the way the referring practice works. Professional respect is expected, however, and Kate recalled a telephone consultation where the referral clinician was “dismissive, rude, and treated me like my problem was blindingly obvious” – needless to say she never referred to them again. Regarding ability, Kate commented that unless she hears a lot of negative feedback, she assumes ability is a given.
The future of referral practice must lie in forming strong partnership relationships and ultimately communication is a key decider for most referring vets – being involved in postoperative management is typically well received if the communication and support is there.
Peggy reflected that her worst experiences with referrals have all been about communication. Kate concurred: “If I am trying a referral centre first time and communication is poor, it makes me fairly unlikely to refer again. If I have a good relationship and have previously referred 25 times and the communication has been good, but on the 26th time the communication is poor, then I’m going to give them the benefit of the doubt. After all, they are only human”.
