Surgeons please help.....

Re: Surgeons please help.....

Gillian Mostyn — Tue, 17 Feb 2015 18:14:27 GMT

As I initially said, it is all about honesty. As long as the client knows what level of service is being provided, and the likely charges, there is no problem. I would hope that they are also being informed about the alternatives... including referral elsewhere if the need for significant post op care is to be anticipated.

Re: Surgeons please help.....

Tim Charlesworth — Tue, 17 Feb 2015 18:02:58 GMT

Just before this starts becoming a "bash the specialist" thread...

How to charge for postoperative complications is really tricky. I have worked in places where they have had the policy of charging full cost for these which may seem harsh but this is made clear on the initial consent form and so everybody is up front about it. Complications happen, yes the fact that a specialist is doing the op should decrease the risk of a complication but don't forget the obvious point that the surgery is, by very nature of it needing referral, more complicated than many routine surgeries and certain conditions (ie not just the procedure) carry complication rates that are the same whoever does them. It is nobody's "fault" if a dog develops seizures following a shunt ligation so why should the surgeon give up his/her time for free if this develops? The important thing is that this risk is explained to the owner during the consultation and that appropriate estimates are given including a "worst case ICU scenario" estimate so that owners know what could happen and how expensive it could be before they start.

The issue of who should pay for more routine postoperative complications is not only a referral practice problem. We don't have a blanket policy. If the complication is one associated with the condition and one that was anticipated and I felt we did all we could to prevent it then we would charge properly for dealing with it. If I felt it was surgeon error then that's different and we would be as sympathetic as possible (eg just charge materials).

Anyway, please remember that the specialists who "charge enough to start with" usually have their fees marked up by the practice which they visit and spend a great deal of their time reading really boring journals, giving ongoing advice to referring vets, planning complicated surgeries and generally trying to be as supportive to the profession as possible.

Rant over, off to eat pancakes..

Re: Surgeons please help.....

Martin Atkinson — Tue, 17 Feb 2015 17:20:24 GMT

[quote user="Evelyn Barbour-Hill"]Personally I find it very strange that anyone would charge for post-operative checks at all.[/quote]I agree but then I read it as post op complications not just a routine check. Whatever, FFS its not like they don't charge enough to start with!!

Re: Surgeons please help.....

Evelyn Barbour-Hill — Tue, 17 Feb 2015 16:25:08 GMT

This exemplifies the problem with "visiting specialists" that nobody seems to have to have thought through properly. Although I'm sure the boss in Anon's practice has thought it through as far as the pound signs. Is she not a veterinary surgeon, I wonder?

I can't see how the visiting specialiost can just do the op and swan off, without leaving several pages of highly detailed instructions, written for the specific patient, preferably briefing personally the veterinary surgeon who will have charge of the case and being available for further consultation if necessary. Certainly they should deal with any complications, and Anon should not struggle on with them. If the boss or the specialist feels the need to charge the client heavily, that is for their respective consciences, greed, commercial acumen and professional ethics to battle ouit.

Personally I find it very strange that anyone would charge for post-operative checks at all.

Re: Surgeons please help.....

Bob Russell — Tue, 17 Feb 2015 15:51:01 GMT

Quite right. I misread it! In this case just book the complications for him or her to sort out! Mood bad, doing PET passports and recovering from teenagers!

Re: Surgeons please help.....

Martin Atkinson — Tue, 17 Feb 2015 15:42:27 GMT

[quote user="Bob Russell"]Clearly what has not been thought through is aftercare responsibility. Why does your boss think he or she is worth £200? [/quote]I read the OP that the specialist is charging their fee for post op complications not the boss which if he was would be very unprofessional.

However, notwithstanding their responsibility for providing aftercare, I feel that there is an obligation on specialists to not charge exorbitant fees if there is a complication especially if it is one that was due to less than perfect treatment/surgery. Indeed as they are charging so much more for their skills the expectation should be that they do a better job. Maybe that is a simplistic view but I've had an issue with an orthopaedic case that was referred to a veterinary school.

The procedure failed in my opinion because it was not performed correctly in the first place and they charged full fees of several thousand pounds to correct it which I thought was most unfair. When it went wrong a second time I campaigned vociferously on the client's behalf that they should reduce their fees. Their argument was that the surgeons had no power over the charging as the bean counters were the ones who set the fees. This I think is bullsh*t and told them so (well maybe not those words)! Maybe someone got a conscience, I can't believe they were in awe of me, and they did in the end reduce the fee considerably but it still wasn't cheap.

Re: Surgeons please help.....

Hannah Wynne Richards — Tue, 17 Feb 2015 15:33:40 GMT

Agree with Tim Bob and Gilian

Wynne

Re: Surgeons please help.....

Tim Charlesworth — Tue, 17 Feb 2015 14:50:15 GMT

This is a tricky one but the bottom line is that if a referral surgeon takes on a case, they need to be available for back up/postoperative care. Now in your visiting surgeon's case I can see it from both sides - why should he/she give postoperative care including follow up visits etc and not be paid for it? What you don't want, however is a complicated "referral standard case" being inadequately monitored/treated in the postop phase as so many of the ST cases can fail at this stage.

One possible solution is that the surgeon should charge more for the initial consultation/surgery but include a first postoperative check in that fee so that this is not seen as an "extra" but ultimately it comes down to case selection. I would have no problems whatever visiting a practice and whipping off an MCT and flapping the wound but I would never do a pyothorax or a portosystemic shunt unless I was completely happy with the OOH provisions/support staff and I was available to go back in over the following few days. It is much easier to do orthopaedics on this basis as the postoperative care is fairly standardised (normally bandage off and home on analgesia..) but the potential for major issues/postoperative complications is the main reason why not many ST specialists will do this sort of work outside of a referral institute.

If the ST surgeon/working arrangement is causing you a lot of stress then I would talk to the surgeon and voice your concerns directly to him/her. I'm sure that, if they know that you are unhappy dealing with certain cases, they will not want to perform those cases at your place of work (it is their complication rate that will go up after all). It may be that your boss has told them that you are all happy to take on all the cases and they may be blissfully unaware of what is actually going on.

Like all these things, talking it through is the ideal. If you want to PM me with any specifics then do, any info treated in strictest confidence,

Tim

Re: Surgeons please help.....

Bob Russell — Tue, 17 Feb 2015 14:40:39 GMT

Nice idea to have specialists come in to do procedures. Not surprised that the boss is happy.

Clearly what has not been thought through is aftercare responsibility. Why does your boss think he or she is worth £200?

I can understand a specialist charging extra for unexpected, 'no blame' complications but this should have been budgeted into the cost of the procedure or owners made aware of the sort of extra charges that will be incurred if there are complications.

There is nothing wrong with this set up but the practice has to decide where financial responsibility lies. Our specialists tend to have a fair attitude to pricing complications and clients are made aware.

If you cannot change practices then you have to decide to walk or report. Reporting will only be of much value (IMO) if animal welfare is compromised. This may result in lousy PR but that is your boss's problem, not yours.

Re: Surgeons please help.....

Gillian Mostyn — Tue, 17 Feb 2015 14:16:33 GMT

From your summary of the situation, it sounds like they are all on very dodgy ground. A referral vet has the same responsibilities as everyone else - to ensure their cases receive appropriate 24hr care. They can't just do their surgery and walk away. Equally, if the boss is charging more for a 'specialist' servoce, this has to be the case. It is all about honesty. Are your clients getting the service they expect, given the information available to them and the money they have paid?

If you genuinely feel that the care of your patients is being compromised, and your boss refuses to address your concerns, then you only have two choices. Walk away or contact the RCVS. It is easier to walk away, but if you feel strongly that the current situation is wrong, then you may have to stand by your principles and ring the RCVS for advice. After all, if your boss is doing nothing wrong then they have nothing to fear!