What’s next? Continuing education and specialism in the UK vet sector

In my previous article (VT52.44), I discussed some of my thoughts on the goals of a residency and where I’m at currently.

It’s a very odd position to be in, coming up to the end of a residency. I’ve spent so long training in a very specific way that I am a little nervous about being on the other side of the training programme.

If we go back to the model of human medicine and its consultancy training, I think we could approximately say I’m somewhere in the realm of the speciality training.

My two years in general practice could be considered similar to the FY1/FY2, my internship to the C1/C2, and the three-year residency as part of the consultancy. Most specialities within human medicine require three to five-plus years of training, so what could I do with the next couple of years?

As I eluded to in my previous article, I am fully aware of the privileged position I am in by even being able to complete a residency. Furthermore, considering additional training might seem bonkers, but I still feel like I have more to learn and more years to devote to this. What are the options? Well, there really aren’t many.

Most people finishing residencies will go straight into private or academic referral practice, and solidify the skills they’ve acquired during their training so far. Some prefer to dabble in other pathways, even including pursuit of a PhD. Even rarer are fellowships.

Where do fellowships fit?

Now, if I could contribute one thing to the improvement of our profession as we begin to learn more and more about veterinary and human medicine, it would be to increase the number of fellowship positions available. Unfortunately, fellowships are incredibly rare and not many institutes feel comfortable offering them – but what do I mean by a fellowship?

Consider the human medicine training paradigm. A fellowship would typically be considered towards the end of the consultancy training and allows sub-specialisation within a given field. While we may not be at a point in our profession’s development that requires sub-specialisation, I can definitely see it becoming an integral part of our future.

A few fellowship positions are available; although, apparently few are open in the UK. As far as I’m aware, fellowship positions have existed in interventional medicine, interventional cardiology, dialysis/extracorporeal therapy, cardiothoracic surgery, surgical oncology, oral and maxillofacial surgery, minimally invasive surgery and joint replacement surgery.

These positions typically last one to two years, and aim to have a specialist follow a colleague with a particular interest and area of expertise – all with the view of cramming in as much exposure to a more narrow spectrum of cases in a short period of time.

For example, I have a particular interest in cardiovascular critical care. Go to any big human hospital and you’ll see multiple critical care units, such as paediatrics, neurology, surgical/medical, and coronary/cardiac critical care.

In the ever-developing world of mitral valve repair, transcatheter edge-to-edge repair and percutaneous atrial septostomy, surely a niche exists for people who manage these patients pre-procedure and post-procedure?

Yes, we’re getting to the nitty gritty and the ultra-specialised here, but only by mastering these interventions and patient management will it become more widespread, making it more accessible for more people and their pets.

Unfortunately, no such training positions are available to us in the UK, or even in the US. Some in my position would consider a clinical PhD; others, more rarely, would consider a second residency. Time will tell, but I hope that by the end of my career, we have more training positions available for those wanting to continue.

Where else could fellowships fit in? I think it really depends on the definition. After all, we aren’t talking about fellows of the RCVS here – that’s completely different.

If fellowships are for post-residency, then perhaps we should consider something akin to a speciality-specific internship for more people. Could we set up centres with diplomat surgeons who take on postgraduate veterinarians for one to two years, with the view to improve their surgical skills so that more can be managed in general practice? Perhaps this could be completed in combination with a formal certificate, such as the Certificate in Advanced Veterinary Practice?

Not everyone can commit three to four-plus years to go down the internship/residency route, but while we maintain a very broad role as general practitioners (GPs) within the UK, maybe adding some additional training for a year or two in a specific area would be good to cram in that experience. This is what a lot of corporate practices are trying to do with their own new graduate programmes, but maybe some collaboration would help get this standardised a bit better.

I view general practice as a specialty discipline in itself. I don’t see us losing the current paradigm of what it is to be a general practitioner for a long time, nor do I want us to.

I think, at least, the next steps would be to stratify our undergraduate training into small versus large animal; although, I can imagine a lot of pushback about that. I’m not suggesting the entire degree should be focused on small versus farm/equine (or other), but maybe just the final year?

I think trying to keep up to date while living the James Herriot dream of seeing consults in the morning and calving in the afternoon is becoming increasingly difficult. Perhaps this division would allow for more focused training of our undergraduates to better prepare them for postgraduate life? Couple this with our own condensed version of FY1/FY2 and who knows – maybe that transition into being a practising vet would be a little smoother.

I don’t have a solution and, therefore, I probably shouldn’t be complaining – although, I’m not sure I’d use the term complaining. Maybe I’m ranting? Yeah, that’s probably it.

I still have a huge, vested interest in the mental health and well-being of our profession. I would be lying if I said I had felt completely healthy at all times during my residency, but I’ve managed to stay sane through the support network I’ve developed in my friends, family and colleagues at the RVC.

People are still leaving the profession, burnt out as ever, and I think we need to have a serious think about what we are expecting from the bulk of our profession – our GPs.

GPs under pressure

I have been lucky through COVID that we’ve been able to limit (mostly) the number of cases we see to appropriately match that to the staffing we’ve had available. Yes, this has meant occasions where we have had to close the service. No, that does not mean we have been sat around with cups of tea in our ivory towers.

But I do feel for my colleagues and friends in general practice; that defence mechanism of being able to say they can’t accept your case isn’t available, and I know for sure that we haven’t been the only referral centre having to carefully select our incoming patients. GPs have had it rough and they are our first line of defence for protecting our pets in the UK.

We expect so much from GPs and it’s getting to a point where we have to wonder whether it is sustainable. Compare a veterinary GP to a human GP – find me a human GP who is consulting and performing procedures such as imaging, surgery and dentistry – all while dealing with urgent care and emergencies.

GPs are the first port of call for many human illnesses, but we also expect to be referred much sooner. I certainly wouldn’t want my GP performing intestinal surgery on me, and while I know a lot of people are drawn to veterinary medicine because of the variety in general practice, I do worry about the rate of burnout and the rising expectations from clients. I would argue that the solution isn’t to accept a lower standard of care because everyone is so stretched for time and facilities, but to outsource more.

Do we need orthopaedic specialists to be performing all the tibial plateau-levelling osteotomy (TPLO) surgeries in the country? I’m about as far off from being an orthopod as you can be, so apologies in advance, but I think most of my colleagues would say “no”.

A TPLO is very different from minimally invasive arthroscopy surgeries or total hip replacements, or even complex fractures. Perhaps having more centres that focus on routine procedures (that also require additional training) would take the pressure off of GPs and referral hospitals alike?

I am glad to see the trend of outsourcing out-of-hours continue, but it still isn’t as widespread as I would like. I work a substantial number of nights and late evenings, but at least when I’m not at work, I can sleep and/or relax. I am yet to feel the same level of stress I felt while on call in general practice.

Ultimately, we all have the same goal. I believe that at the heart of every veterinary student is still a desire to improve animal welfare, in one way or another.

I think we’re entering an incredibly exciting age of the profession and it’s amazing to see the huge amounts of research that is being generated – especially large-scale epidemiological studies that are showing us how patients are being managed all over the UK. But at the same time, we have to use this data to come up with solutions to make a more sustainable profession. We need a medium to discuss these profession-wide challenges that doesn’t devolve into a social media rant of “he/she/they said…”

That’s all folks!

If at any point you have a question or want to discuss a topic from ECC Endeavours, please feel free to drop me an email at [email protected] and I will try to get back to you ASAP.

Until next time, take care. As always, the views expressed in this article are mine alone, and do not necessarily represent the views of my employment or affiliated institutions.