How is competence defined?

RE: How is competence defined?

Clive Ansell — Wed, 19 Jan 2022 14:43:30 GMT

[quote userid="19228" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235266#235266"]With millions of households heading into fuel poverty, we are discussing encouraging the 800 cat dental ?[/quote]

Again, that is a societal problem for governments to sort out, or more likely not. It is not for us and our profession to work out or solve.

I wouldn't encourage any particular fee for the so called dental, but it needs to be fair. I'm against ripping people off, but I don't agree with working on the cheap either. Where I am at the moment, most car dental procedures cost around £350, one yesterday was an elderly cat that I extracted all remaining teeth as they were loose, and including bloods and fluids (early renal disease) was about £380. seems perfectly reasonable to me.

[quote userid="19228" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235266#235266"]With vet time availibility at crisis point we need to make standard proceedures last 3 to 5 times as long?.[/quote]

No, but we need time to do things properly and not rush. I'm no fan of cramming in another dental in the 20 minutes before lunch.

RE: How is competence defined?

Evelyn Barbour-Hill — Tue, 18 Jan 2022 14:10:12 GMT

[quote userid="2675" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235265#235265"]Marie Antoinette- The people are starving, there is no bread. Well let them eat cake (or so my history was taught to me)[/quote]

Ah.

She never said any such thing. It was a slur circulated by her many enemies.

Rather like that thing about Queen Elizabeth 1st "She took a bath every year, whether she needed it or no".Lies, calumnies and myths often turn into history.

RE: How is competence defined?

cairncross — Tue, 18 Jan 2022 08:45:21 GMT

With millions of households heading into fuel poverty, we are discussing encouraging the 800 cat dental ? With vet time availibility at crisis point we need to make standard proceedures last 3 to 5 times as long?.

Where should the guillotines be situated?}

RE: How is competence defined?

Richard Carter — Tue, 18 Jan 2022 07:50:26 GMT

Marie Antoinette- The people are starving, there is no bread. Well let them eat cake (or so my history was taught to me)

RE: How is competence defined?

Clive Ansell — Sun, 16 Jan 2022 13:20:58 GMT

[quote userid="12375" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235201#235201"]

Perhaps the rent on their preemies is more than yours, perhaps they pay their assistants more, perhaps they want to send their children to a more expensive school than yours attended.

Don't be resentful of the more expensive practice: bathe in the self satisfaction of doing a better job for less money or put your prices up and buy a bigger yacht.

[/quote]

There's room in the market place for all, be it a cheap and cheerful high volume clinic, or a do less charge more standard of care. I prefer the latter, and if putting up my own plate, that is what I would choose to do.

In my first job, 1996-2001, we were a busy fairly standard cheap 3 vet practice. A low cost clinic opened very locally offering £12 consultations, £45 bitch speys and the like. We and other local practices were worried initially, but my boss and the practice owner decided to put fees up rather than down, work to a higher standard, offered more work ups where needed, bought more equipment, and we all did more CPD. End result was we did less work, were less stressed, and profits I'm told actually went up. In addition the moaners, bad debters and floating clients vanished overnight, although overtime some of them came back. I think we lost about 10% of the client base overall.

RE: How is competence defined?

Alastair Welch — Fri, 14 Jan 2022 21:49:49 GMT

Perhaps the rent on their preemies is more than yours, perhaps they pay their assistants more, perhaps they want to send their children to a more expensive school than yours attended.

Don't be resentful of the more expensive practice: bathe in the self satisfaction of doing a better job for less money or put your prices up and buy a bigger yacht.

RE: How is competence defined?

Evelyn Barbour-Hill — Fri, 14 Jan 2022 21:26:55 GMT

[quote userid="2675" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235144#235144"]We now have real situations where, as we talking dentistry, an elderly cat dental with extractions and some basic aftercare (pain relief etc) will be upwards of £800 (bloods, iv fluids, possibly X-ray). This isn’t specialist, this is basic vet working for corporate type practice. The happy go lucky practice down the road who will shove in some s/c fluids, might manage to do same for £250-350. Who do you think is doing the work and how many cats that really need dentals are now not getting them? Who is actually helping animal welfare and who is at the risk of making all their training and equipment irrelevant? Or is this post actually about forcing everyone to the £800 plus dental? In which case this really is a Marie Antoinette moment with a complete indifference to our patients situation.[/quote]

Well, once again, there's this term "dental" used, as if it referred to some recognised procedure. All I can say is that if I did a COHAT ("complete oral health assessment and treatment"), including radiography of course, necessitating some extractions – and I am not a Specialist, but in my less modest moments I do lay claim to being an expert – on an elderly cat, it wouldn't be a "happy go lucky " job and I wouldn't "shove in some s/c fluids". There would be no blood tests. Depending on how many extractions were needed, it would be maybe £400.

When I first started doing periodontic work properly (about 1986) the client's expectation was for a "scale and polish and extract the worst"; more pithily termed the "pull and scrape" and they expected to pay about £25 to £30. I started doing proper work, but at first I only charged ridiculously low prices, just to get people to have it done. Then the charges gradually rose until the work did at least turn some sort of profit. Until now, when if the bill actually did come to £800 plus VAT I would not be remotely embarassed; and the size of the bill would be because of the work involved, the quality of the work and the time it took, not because it was jacked up by unnecessary add-ons..

So I would resent any bog-standard practice muscling in and doing a scrape and pull for £800!

[quote userid="2675" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235144#235144"]Marie Antoinette[/quote]

Puzzled by that. Please explain.

RE: How is competence defined?

Thomas Johnson — Fri, 14 Jan 2022 15:03:13 GMT

[quote userid="9239" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235087#235087"]I shouldn't really speak for Michael but I don't think this is what he said. But for certain procedures (not all ortho work is extremely difficult just like not all soft tissue surgery or in any other field) an experienced GP vet might find themselves in a situation where they never performed a certain procedure before but they did perform others just as or even more complicated. [/quote]

I think this is a really interesting point. I did my first perineal hernia repair in a dog last year, the owners couldn't afford referral, and having read up on the procedure I felt it was within my capabilities, I explained this to the owner and they were happy for me to go ahead. The surgery went well, and the dog did very well afterwards, but I found doing it quite stressful to do, and worried about it more than I would after other surgeries. Would I describe myself as competent at the procedure? I think that's a difficult question to answer, this one went well, but another one might have different challenges. Would I do another one? Yes, but I would still recommend referral if the owners could afford it.

RE: How is competence defined?

cairncross — Fri, 14 Jan 2022 14:27:32 GMT

The spays and neuters no i dont think they are economic at those rates if you factor in how many want an ooh check up because the stitches are red itchy etc we have dropped out, some are still running this.

This ability to imeadiately blow funds on pup tattoo fake tan personalised numberplate does not reflect well on ability to plan for day to day living.

Parents have some property lets had to go to one last week to quickly help Dad with heating. Most residents have all the above spontaneous purchases but no heating oil Heating rarely gas here. They dont buy heating oil and boiler airlocks or boiler pump ingests water from condensation..It is a continuous process fixing these which i have got the knack of over time. Accelerated now due to oil prices.

At 150 to 200 pounds we get drop out from opting for proceedures, in significant ammounts.

RE: How is competence defined?

Clive Ansell — Fri, 14 Jan 2022 13:48:43 GMT

[quote userid="19228" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235174#235174"]It is worth what the economy can pay for it. [/quote]

I wouldn't have thought it possible to it that cheaply?

Strange how these folk with no money always find £1000's to buy a fashion accessory puppy though?

RE: How is competence defined?

cairncross — Fri, 14 Jan 2022 13:19:03 GMT

It is worth what the economy can pay for it.

RE: How is competence defined?

Clive Ansell — Fri, 14 Jan 2022 12:37:44 GMT

[quote userid="19228" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235171#235171"]Dogs trust pay us i think 45 pounds for dog castratevand cats prptection ibthink 35 for cat spay[/quote]

That's ridiculous. Our skill and professionalism is worth more than that. I'm sorry, but it is.

RE: How is competence defined?

cairncross — Fri, 14 Jan 2022 12:03:51 GMT

Dogs trust pay us i think 45 pounds for dog castratevand cats prptection ibthink 35 for cat spay.ypu have to turn over greater numbers in smaller period of time have less support staff work longer hours yourself i do the admissions at 7am myself etc . It depends on anyones catchment area NI has the lowest incomes in uk.

Standards expectations etc have got to reflect the circumstances.

RE: How is competence defined?

Clive Ansell — Fri, 14 Jan 2022 11:55:08 GMT

[quote userid="19228" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235163#235163"]At 100 pounds my clients opt for dentals in reasonable numbers at 200 they dont[/quote]

It's not even £100 though. its £83.40 + VAT. How on earth can you make that pay?

RE: How is competence defined?

cairncross — Fri, 14 Jan 2022 08:45:40 GMT

There are 300k doctors looking after 70million people with a budget of 140 billion 300k nurses tens of thousands of paramedics pharmacists dentists midwives etc.

We have 29k vets many part time some acting ad lifestyle coaches homeopathists and morning specialists. Looking after 250 million pwned animals with a budget of 5 billion before we take out the cost of servicing the tens of billions of practise debt recently aquired.

At 100 pounds my clients opt for dentals in reasonable numbers at 200 they dont. Average family weekly disposible income here was 100 pounds but is probably less now

RE: How is competence defined?

jd2008 — Fri, 14 Jan 2022 01:21:20 GMT

[quote userid="4331" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235152#235152"]probably the most reliable non-seasonal income stream a practice has is often performed by hungry and tired staff at the end of a session with badly maintained equipment and negligible training. That’s the real problem. Not who does a root canal [/quote]

Spot on.

Critical self-reflection has been mentioned by Rachel earlier. There's a version of this that can be used to identify barriers to improved performance in a clinical setting. Indeed, it forms part of mandatory peer consultation for psychologists. In brief, by objectively critiquing your performance (of a procedure, group of procedures, client interactions, peer interactions etc.) you can identify what went well and why, and what didn't go as well and why. This information then equips you to take appropriate steps to enhance future outcomes.

The emphasis is very much on avoiding value judgements about the practitioner/yourself or your performance as these are unhelpful and mostly meaningless (e.g., you or your performance is not 'bad' or 'careless'). In the situation described by Norman, reflective practice would identify the various internal or external factors that affected outcome (inadequate equipment, tiredness, distraction etc.) without making any judgement about the practitioner's character or value.

Personally, I've found this to be a valuable tool that has allowed me to critique my own work without spiralling into feelings of overwhelming guilt, inadequacy, low self-esteem etc. that were frequent sequelae to poor outcomes or poor decision-making in my earlier career and put in place meaningful and effective strategies to both improve outcomes and avoid poor outcomes for future patients.

[quote userid="2675" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235144#235144"]

Can we talk about the real world and not the 10% of highly specialised experts- this is practice standards mk2 where people are closing the door on people lower down the ranks because of not meeting the ‘standard’ which is already better than the vast majority of the rest of the world.

We now have real situations where, as we talking dentistry, an elderly cat dental with extractions and some basic aftercare (pain relief etc) will be upwards of £800 (bloods, iv fluids, possibly X-ray). This isn’t specialist, this is basic vet working for corporate type practice. The happy go lucky practice down the road who will shove in some s/c fluids, might manage to do same for £250-350. Who do you think is doing the work and how many cats that really need dentals are now not getting them? Who is actually helping animal welfare and who is at the risk of making all their training and equipment irrelevant?

[/quote]

Absolutely. There are situations in the 'real world' as you describe above where, due to financial constraints etc. and for the sake of animal welfare we must perform procedures on animals that are not necessarily the ideal option. However, I think there is an important distinction here between those cases and ones where there is an alternative, conservative or palliative option which may be dismissed too early and without adequate justification by those keen to 'have a go'. As an example, my first ever attempt at a skin graft failed miserably. As is the way with these things, it took its own, sweet time to fail too, meaning the dog was subjected to repeated revisits, sedation, dressing change and the associated pain and distress, and was left with extensive scarring; much worse than if I'd simply left the original defect to granulate.

Looking back on this, I can recognise that the 'sum of the technique' in terms of outcome was much more than the 'parts' of simply following the written description, using all the correct equipment, correct post-op management etc. One of the (many) reasons that graft failed was because I had no idea of knowing what "careful handling" of the graft actually felt like in my hands, or just what too much suture tension was.

I have also watched as a dog was subjected to an initial procedure that failed followed by two failed revision attempts, resulting several months later in amputation. In the intervening period the dog had to endure prolonged confinement and discomfort. Had the practitioner opted for conservative management at the start the outcome would not have been perfect, but the dog would have kept his leg and returned to adequate function relatively quickly with significantly less overall suffering.

These are the types of cases where I find 'having a go' concerning, not the cases where you are backed into a corner financially or otherwise with no reasonable palliative or conservative option. Regardless, I still think we should be critiquing these procedures to identify where we can improve future outcomes. Some barriers we won't be able to remove but any ones that we can, we should.

RE: How is competence defined?

Clive Ansell — Thu, 13 Jan 2022 20:46:49 GMT

Were I am working at the moment, a small independent 2.5 fte vet practice, feline dentals are usually in the region of £300 - £350, plus any bloods tests, i/v fluids, or medications as indicated. There is no upselling, or staff on commission to peddle bloods and fluids, they are advised as the clinician sees fit. It is a good well equipped practice that works to a good (first opinion practice) standard. 1 or 1 and 1 /2 days, as needed, a week are specifically set aside for only dental procedures, so they receive the time and attention they should.

I've never seen a cat there that has had dentistry exceed £500, and most are around £350. That to me seems very reasonable, when I have seen cases that have been to local corporates topping a £1000.

RE: How is competence defined?

Norman Johnston — Thu, 13 Jan 2022 14:38:56 GMT

Hello George! As I recall you were one of the first delegates in our Birmingham Dental School/ Schein courses from 1991. As I look back on CPD provision over 35 years I realised quite quickly that almost all vets just wanted to do routine dentistry better. I agree with that totally. I expect my own dentist to do exactly the same and if I need something more involved he shunts me off to a specialist. It’s happened twice in my life and my own choice entirely.
The other interesting point is the cost of routine dentistry. For decades I was told by delegates that owners wouldn’t pay more than £100. Suddenly it’s open season for cost! Where did that come from? I don’t think I really need to ask that question.
Bob made a decent point that a dental problem can be resolved by extraction in almost all cases. That remains the remit of the GP in my view although things changed when the typical multigenerational practice changed to one where newish grads with minimal mentorship worked in isolation. We started to get canine and carnassial extractions referred then.
I’m still firmly of the view that GPs need to do the basics well in a properly equipped environment with decent training. In lectures I talk about the paradox that probably the most reliable non-seasonal income stream a practice has is often performed by hungry and tired staff at the end of a session with badly maintained equipment and negligible training. That’s the real problem. Not who does a root canal

RE: How is competence defined?

Richard Carter — Thu, 13 Jan 2022 10:10:08 GMT

RE: How is competence defined?

George Cooper — Thu, 13 Jan 2022 10:01:49 GMT

I almost dared not cast my 2pennorth little thoughts into this most erudite and informative jumble of threads to have surfaced within VetSurg dot org for many a moon - BUT - a comment from Rachel stirred an uncomfortable memory of the situation that led to this VS resigning peremptorily from the employ of the Corpse that took over (and decimated at a stroke) our well loved and respected and happy family orientated practice in The Valleys a couple of years ago.

In a "meeting" with "Regional Director" and a couple of other minions, they were at pains to attempt the persuasion of "us" of the benefits of their so-called gold plated aspersions for a general practice such as ours, The ENTIRE discussion centred around PROCEDURES with zero attention to OUTCOMES, something that even now threatens to overwhelm my sensitive belief in what we strive for in practice, despite having "retired" from active slavery for nigh on 2 years now.

RE: How is competence defined?

Rachel Perry — Thu, 13 Jan 2022 08:24:12 GMT

Jd2008, thanks for posting this conversation summary with your friend, it’s really interesting. While veterinary expected standards are defined by a number of stakeholders (RCVS, the client, employers, specialists, APs, peers- all hopefully evolved using best available evidence) what I feel we lack is the objectivity that your friend describes. All EBVS and RCVS specialists have to re-accreditate every 5 years, when we present evidence of caselog, publications, teaching, research etc. We don’t provide objective audits on outcomes though which is interesting.

I do feel we could do more to improve expected standards of dentistry . For instance, any specialist, AP, certificate holder or GP with an interest in dentistry would say one expected standard is to include dental radiography when performing dental procedures.- and there’s evidence to back this assertion which is over 20 years old. The last time I looked at the RCVS Practice Standards Scheme, dental radiography was only included at hospital level. I’m not sure if this has now changed ?

RE: How is competence defined?

Rachel Perry — Thu, 13 Jan 2022 08:07:45 GMT

Hi Kate,

I agree with you and believe the vast majority of vets do what you describe. I don’t think I explained myself very well with my earlier comment. Critical self-reflection is different from self-reflection and that’s what I think vets are not good at or perhaps practised in. Critical self-reflection is much more introspective. It includes feelings and emotions as well as processes and outcomes and also involves looking at events through different lenses (e.g through the eyes of the client, employer, colleague, animal etc) . I only realised I wasn’t performing critical self reflection when I studied for the PG Cert in veterinary education. It can be quite an uncomfortable process. If you’re interested in reading more about it, Mezirow did the seminal work on it in the 90s

RE: How is competence defined?

jd2008 — Wed, 12 Jan 2022 23:26:48 GMT

Great points! My thoughts:

[quote userid="9239" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235125#235125"]How can the standard of competence be achieved? Everybody is overworked so having a senior vet hovering for multiple surgeries is almost impossible. It would double the bill. The chances of seeing practice in a referral centre these days are close to zero and many vets don't want to see practice in their days off, they want CPD days. Who pays for them?[/quote]

This is what residencies are for . Obviously this is a ridiculous route for the more straightforward procedures or (and this is where it might get tricky or controversial) procedures that owners perceive as routine and expect a GP vet to perform (ovariohystercetomy and orchidectomy are the obvious ones to start with). I believe, but could be wrong, that these are the sort of procedure that the schools define as day 1 skills or similar so they are still taught under supervision, or that's the aim at least.
I've seen a lot of angst on other forums from vets bemoaning the lack of 'alternative' routes to specialisation. These posts seem to miss the point that the complex and challenging nature of specialist procedures means there's no short cut you can reasonably take to competence.
To be blunt, and this is only my opinion of course, if you don't have the time, willingness or resources to learn a procedure or field properly then don't touch it - leave it to those who can

[quote userid="9239" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235125#235125"]If the recognised specialist put the data together, can they be objective about the outcomes of GPs or cert holders? Maybe an universal data base? It will still be subjective though. [/quote]

True. I wasn't clear in my wording (apologies). As you say, specialists setting standards for non-specialists would be fraught with all sort of issues. It would require a collaboration between all tiers to take the specialist data and agree upon reasonable benchmarks for GP and cert tiers. In my head I see it working in a way similar to policy development: start with data and wide consultation -> draft proposal -> targeted consultation on the draft and amend as required -> release and instigate agreed benchmarks -> collate data from all tiers over a period of time -> review benchmarks accordingly.

[quote userid="9239" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235125#235125"]What do we do if a certain standard of competence becomes a requirement before any procedure regardless if the owner might have been happy for someone less competent to do the surgery? Is it right to compare vets and human surgeons? Weren't we historically a combination between a doctor and a farmer? [/quote]

Can we compare vets to human surgeons? Realistically not to the extent that this discussion can ever be anything other than theoretical. An intersting waste of time, nonetheless
I suppose one of the complicating factors here is animal welfare. Back when vets were doctor-farmer hybrids we had a very underdeveloped concept of animal suffering. We now accept just how complex animal suffering is and have an ethical obligation to take that into account when we consider 'having a go'. There are cases I can think of where the procedure has failed and I strongly suspect the net welfare outcome for the animal would have been better if the surgical procedure had not been attempted at all. How do we align owner wishes with animal welfare? I honestly don't know.

RE: How is competence defined?

Michael Woodhouse — Wed, 12 Jan 2022 23:14:47 GMT

[quote userid="2180" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235119#235119"]- In Australia, all surgeons are required to conduct an annual audit of their surgical outcomes and submit that for peer review. As much as anything, this is a data gathering exercise that enables the setting of 'acceptable' complication and success parameters [/quote]

Yes, but the more I think about this the harder it becomes in vet medicine. I'm sure that the recognised specialist anaesthatists have a higher anaesthetic mortality rate than me and a student nurse, but that's a reflection on the patient population. Straightforward comparing human surgeons replacing hips, but my surgical workload is likely to be very different to most other people on here. Currently I'd estimate I am 70% large animal with my small animal surgical caseload being 33:33:33 routine:emergency:more complex surgery. I can go a couple of weeks with no small animal operating and then get a week like this with more (alongside cows). Who are you going to compare my splenectomy to?

RE: How is competence defined?

Dinu Catilina — Wed, 12 Jan 2022 22:52:38 GMT

[quote userid="2180" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235119#235119"]

This is, perhaps, the crux of the issue. The conversations occurring in this thread and others over the past few days gave me the nudge I needed to call up an old friend who's a human ortho and ask exactly this. To summarise from that conversation:

- Standards are constantly evolving in all specialist disciplines. Driven by various factors including increasing evidence, technology, improvements in post-op management, and surgeon's technical skill.

[/quote]

Thank you, this is where I was trying to get, some kind of objective definition of what the expected standard is. Because, like it was said earlier, it might be very easy to believe we are competent where we are not.

[quote userid="2180" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30143/how-is-competence-defined/235119#235119"]Putting the bits about standards together, perhaps this is where we could call on the recognised specialists to get together, collate their outcome/complication data from which e a tiered standard (specialist, cert holder, GP) could be devised based on defined outcome and complication measures. Or does this already exist?[/quote]

There are some in the ortho field, thinking mainly about hip replacements and now the cruciate register but not much. The idea is great but who has the time and who will pay for it?

And I still have three concerns

1. How can the standard of competence be achieved? Everybody is overworked so having a senior vet hovering for multiple surgeries is almost impossible. It would double the bill. The chances of seeing practice in a referral centre these days are close to zero and many vets don't want to see practice in their days off, they want CPD days. Who pays for them?

2. If the recognised specialist put the data together, can they be objective about the outcomes of GPs or cert holders? Maybe an universal data base? It will still be subjective though.

3. What do we do if a certain standard of competence becomes a requirement before any procedure regardless if the owner might have been happy for someone less competent to do the surgery? Is it right to compare vets and human surgeons? Weren't we historically a combination between a doctor and a farmer?