Referral to an internist is often in the best interest of a patient, particularly if the case involves a chronic, refractory, or undiagnosed condition. Unfortunately, many pet owners cannot afford the cost of referral. In these instances, the general practitioner is challenged with treating these complicated cases on a limited budget. Owners may even elect euthanasia due to cost of care. General practitioners may seek guidance from an internist in order to discuss diagnostic and treatment options for patients that need referral care but whose owners cannot afford it. Such consultations are frequently limited to a single phone conversation or email, and outcome is therefore unknown by the consulting internist. Additional strategies to improve options and outcome in these financially challenging cases may be beneficial to both general practitioners and patients. Furthermore, increasing the awareness of and preparedness of veterinary students for these challenges may improve their abilities to approach cases more efficiently when owners are on a limited budget.
A descriptive study was performed to determine the usefulness of on-site consultations with a boarded internist, case follow-up with an internist, and written diagnostic and therapeutic protocols for selected internal medicine conditions. Fourth-year veterinary students participated in weekly on-site consultations and development of protocols. A total of 35 veterinarians and 15 small animal veterinary practices participated in the study. Each practice was visited three times over the course of one year, and 133 total consults were conducted. A collection of 38 protocols for different internal medicine conditions was given to each practitioner.
Data was collected from pre- and post- participation surveys of fourth-year veterinary students and participating veterinarians. Prior to participation, 90% of veterinary students did not feel confident choosing the best diagnostic and therapeutic approach to internal medicine cases when owners were on a budget and could not afford referral. 100% of students felt that training in this area should be part of their education. After participation in the on-site consults and protocol development, 63% of students felt confident choosing the best approach to these cases, and 59% were "highly likely" to use the protocols in general practice.
Lack of a diagnosis, uncertainty about the most appropriate diagnostics, and the need for a special procedure were the three most common reasons general practitioners recommended referral. Over 50% of participating veterinarians noted that only 25% of dog owners agreed to referral, and 94% of veterinarians noted that expense was the primary reason owners declined referral. Only 28% of veterinarians were "always comfortable" with these cases and 72% were "sometimes comfortable." 83% of veterinarians expressed the desire for lower-cost options, such as treatment protocols, when owners cannot afford referral. After completion of the project, 83% of veterinarians noted that both the on-site consultations and protocols were "highly beneficial." The areas of greatest improvement were their comfort level with treating referral-level cases in general practice, case outcome, and patient care. 100% of veterinarians believed that patient quality of life improved, and 100% wanted to continue participating in on-site consultations.
In summary, on-site internal medicine consultations and cost-effective diagnostic and treatment protocols for various internal medicine conditions benefitted both veterinary students and general practitioners. The cost of veterinary care, especially referral medicine, is not affordable for many owners. Veterinary students should be exposed to these challenges and should be trained in the most cost-effective approach to these cases. Similarly, general practitioners may be able to more successfully and efficiently diagnose and treat challenging internal medicine cases with the proposed strategies when owners decline referral.
Mississippi State University
Dr. Alyssa M. Sullivant is an Assistant Professor in Small Animal Internal Medicine at Mississippi State University. She received her DVM in 2007 and practiced small animal medicine and surgery for 5 years before returning to Mississippi State University in 2012 for an internal medicine/oncology internship and an internal medicine residency. She is board certified by the American College of Veterinary Internal Medicine. Her primary research interest is canine and feline gastroenterology. She also enjoys consulting with referring veterinarians and teaching veterinary students how to approach internal medicine cases in general practice.
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