Certificate holders offering referral services

RE: Certificate holders offering referral services

Stephen Courtney — Fri, 21 Jan 2022 22:38:00 GMT

I have a BSAVA CertSAM - took three years of study but very handheld which I appreciated , and I loved the entire process. I tried the old RCVS style CertSAM years ago, but the compete lack of mentoring was a disaster for me, and I ended up doing conversational French for years instead. Now wish I'd gone for Spanish ....

I decided not to apply for AP status - eligible but to be honest I don't practice at that level, seems pointless and misleading to clients.

I am what I always was, a good GP, but now have a much better understanding of how to investigate things. some of which we do in house, some of which we refer

In the current climate, we now refer more things than we used to as we cannot accommodate all that we used to due to lack of staff

FWIW I transfer cases to our hospital, and prepare people for the possibility they may need to be referred onwards...or upwards

RE: Certificate holders offering referral services

Dinu Catilina — Wed, 19 Jan 2022 22:39:07 GMT

[quote userid="9515" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30144/certificate-holders-offering-referral-services/235289#235289"]Some corporates are using hospitals as referral centres entirely staffed by certificate holders. Not all certificates are equal. And what about Advanced Practitioners - no-one seems to care about them/us![/quote]

This in itself shouldn't be a problem as long as they are honest and specify they are not specialists.

We just had to refer a glaucoma case to a referral practice with two certificate holders. Our reception called ALL the referral hospitals that we know to have specialists in their team trying to get an appointment and we could not get anything sooner than 2 weeks. In the end we found the service of the cert holders excellent.

RE: Certificate holders offering referral services

Clive Ansell — Wed, 19 Jan 2022 16:17:43 GMT

Another thing I have seen happening for a while, is the term "referral" being misused or misleadingly used.

In the satellite branches of two local corporate chains, they use the term "refer to our hospital" or "refer for surgery, or x-rays etc" Colleagues at these main centres (They are not hospital status!) are not certificate holders, not diplomats and not recognised specialists. They are Joe Bloggs MRCVS that happens to work in the main centre.

Clients I have spoken too are confused by this, they think "referral" is to a higher, better, or more expert standard of care, when usually it is not.

Same is true with OOH centres, many clients seem to think they are specialist centres staffed by "emergency vet" or "ER vets" Of course, again, they are not.

RE: Certificate holders offering referral services

Sarah Keir — Wed, 19 Jan 2022 15:59:55 GMT

The middle tier of services in increasingly important - general practitioners are deskilled and time extremely limited.

Some corporates are using hospitals as referral centres entirely staffed by certificate holders. Not all certificates are equal. And what about Advanced Practitioners - no-one seems to care about them/us!

It is beholden to every vet to make it clear to the clients what level of referral they are getting. However, in some business structures it is very difficult (or even impossible) for employees to refer to whoever they want. This is part of what I love about being a locum and I even have it written into my contract that it is MY choice, in discussion with client as to where I send MY cases.

Conflict of interest - I offer a consultancy service in the form of peripatetic medicine and ultrasound services to partner practices. I am an Advanced Practitioner but I am also clear about what I can and can't do. A lot of what I offer, I would consider to be general practitioner level but many vets are deskilled due to years of referring cases to other practices or referral centres, have low confidence to tackle anything and don't have a decent ultrasound machine (I've just spend £30k on mine). I hope colleagues can see what level I am offering and I'm more than happy to discuss.

RE: Certificate holders offering referral services

Anthony Dennison — Mon, 17 Jan 2022 11:26:29 GMT

I have a CertAVP(SAM) which I've held for almost 5 years. I will see internal referrals from vets within our practice, but I do see the occasional non-client. I always make it clear from the outset that I am not a specialist but have a bit more training on certain areas and special interests in specific 'ologies' so can help with the lower price tag.

If I can't do it or think it is beyond me I will decline the referral and suggest a specialist.

We have a CT scanner; a lot of local practices ask to refer a spinal patient to use for a CT, as we don't regularly do myelography we recommend MRI instead. We used to CT a lot of spines but too often the report will recommend and MRI so we normally advise this now rather than wasting a client's money and time

RE: Certificate holders offering referral services

cairncross — Mon, 17 Jan 2022 06:53:34 GMT

If there were a set of rules and clearly defined wording which i actually thought there were it would make no difference. A new form of wording will appear, Cardiac opinion practise, orthopaedic exclusive surgeon.

There has been a proliferation such that i no longer know who works where and what qualification they have or which days they work each firtnight and dont have time to keep up.

Unfirtunatelybwith proliferation and advertising and chasing of cases we get lots of end stage cases seeling secind opinions. Old advanced cardiac cases espscially that have been managed for months and years and now we have been carefully managing expectations and gently prepari g owners fir the inevitable when they go off to a specialist they see advertised seeking effectively a miracle, somevtweak ti treatment will be offered and we get blamed for not offering this, the pet still passes as we were preparing but the tweak is interpreted as if only the gp vet had swapped from one brand of meds to anothef identical Tiddles would have lived for ever..

Renal failure cat 18 my approach is to vaguely mention options but major on preparing owner for pts and reach this stage asap to reducevstress on both them and the animal, a rollercoaster of emotions over 6 or 8 weeks in which the insurance limit is extracted is not good. For this owner and this case and it reduces affordability for thisevwho need it.

These questionable cases are increasingly frequent not at all rare and stir up lots of trouble.

RE: Certificate holders offering referral services

Steven Odell — Sun, 16 Jan 2022 19:53:09 GMT

I have to agree here. I offer a service to some of the practices around me. I have a surgery certificate but am acutely aware that not all certificates are the same (cue discussion in another thread.......!) and that clients must be made aware of what I can and can't do. It's that old chestnut of informed consent and communication.

However, I see that this middle tier has an important place. More and more first opinion practices have deskilled with respect to surgery and orthopaedics in particular, and in terms of kit may only have a few rusty old IM pins stuck at the back of a cupboard, and the only ortho-confident vet was the senior partner who has just retired or lost interest. A client with a pet with a fracture, cruciate or luxating patella may be stuck between the primary clinician who can amputate or euthanise, or referral to a large hospital where no bill ever seems to be less than £3k. However, a significant number of clients can usually find £1-2k and it is this market which I am serving. The clients with no insurance and some funds(not a limitless pot though), or with a less than ideal policy make up quite a proportion of pet owners.

I was brave enough to do a cruciate for a family friend a few months ago (curse of friends and family and all that!), and when I discussed it with him before he drove the dog to me he put it quite nicely. "When you need your car serviced, you don't necessarily need a Formula One mechanic, just someone who is confident and competent enough to do it." It's just ensuring we are confident and competent that is the tricky part!

RE: Certificate holders offering referral services

jd2008 — Wed, 12 Jan 2022 03:49:13 GMT

[quote userid="16672" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30144/certificate-holders-offering-referral-services/235081#235081"]The certificate system is something I do miss a little from the UK - it allows for career progession without completely upending your life (such as for residency) whilst remaining in a practice you may have become attached to and gives clients (and your patients) an elevated level of knowledge and expertise that can be beneficial for all. It also offers an elevated service at a lower proce point for clients who may be unable to proceed financially with a specialist.[/quote]

I completely agree, though I feel this elevated service should be offered within a general practice context.

[quote userid="16672" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30144/certificate-holders-offering-referral-services/235081#235081"]n my first job our IM cert holder was "internally referred" patients but it was also he who was the one who referred the most to local board certified IM specialists.[/quote]

I have worked alongside cert holders with a developed degree of insight like your colleague but also cert holders who would not refer further, seemingly believing their certificate meant they could handle anything. And this is where it becomes problematic. In a GP context, if it were my client and patient, I could (and did) bypass the second type of cert holder where necessary and refer on to a specialist. Who steps in when that cert holder is working in a referral centre without a specialist overseeing their work?

This is, perhaps, one of the greatest advantages of going through the residency pathway. The insight required to know when you have reached the limits of your ability is not readily attained without someone more expert quietly and constantly peering over your shoulder.

RE: Certificate holders offering referral services

Martin Hamilton — Wed, 12 Jan 2022 03:19:19 GMT

[quote userid="2180" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30144/certificate-holders-offering-referral-services/235080#235080"]

I will add that the Australian vet boards are particularly strict about how non-specialist vets represent themselves and their services, the following recommendations from the Australasian Veterinary Boards Council have been adopted by all the State/Territory Boards:

That the use of the full term ‘Registered Specialist’ be encouraged for those who are registered specialists.

That the meaning of the terms ‘Resident’ and ‘Intern’ are clearly communicated to the public.

That the profession is made aware of examples of acceptable and unacceptable use of titles. For example,

‘professional interest’ – in a particular field is acceptable
‘particular interest’ – acceptable
‘non-specialist’ – a negative title and uses the ‘s’ word and thus unacceptable
term ‘cat vet’ – acceptable
‘cat expert’ or ‘special interest in cats’ – unacceptable
the suffix ‘ist’ is acceptable for those who do not deal directly with the public (e.g. pathologist)
‘ist’ is not acceptable for those who deal directly with the public unless the vet has specialist registration—
g. ’acupuncturist’
“consultant to” is acceptable
“consultant in” a particular field implies specialisation and is not acceptable

[/quote]

This is almost identical to North America, which is exactly why I had requested Arlo change the profile selections from "ist"'s to the field in which forum members limited their practice to (which he has thankfully done, thanks Arlo!).

The certificate system is something I do miss a little from the UK - it allows for career progession without completely upending your life (such as for residency) whilst remaining in a practice you may have become attached to and gives clients (and your patients) an elevated level of knowledge and expertise that can be beneficial for all. It also offers an elevated service at a lower proce point for clients who may be unable to proceed financially with a specialist. I certainly appreciated my first practice having a cert holder in IM when I was a new grad, as I'm sure most would.

In my first job our IM cert holder was "internally referred" patients but it was also he who was the one who referred the most to local board certified IM specialists. Certainly as I proceed through a residency program I feel like the more I learn, the more I realise what I do not know.

In my personal opinion I think the certificate system is great, and as long as referral centres and GP practices are transparent with clients about the qualifications that the vet they are seeing has, then it's not a problem. I think that it is partly the referring vet's obligation to the client to research where they are referring patients to, and to understand the qualifications which the referral staff have.

A chain along the lines of the following is what I envision in most cases:

GP -> Cert holder (using titles such as "professional interest in..") -> Specialist (board-certified/RCVS recognised specialist)

Or, if a client wishes or is "high maintenance":

GP -> Specialist (board-certified/RCVS recognised specialist)

Though of course there are outliers and those that will not fit the mould, as is the way of vet med!

RE: Certificate holders offering referral services

jd2008 — Wed, 12 Jan 2022 02:57:58 GMT

That the use of the full term ‘Registered Specialist’ be encouraged for those who are registered specialists.

That the meaning of the terms ‘Resident’ and ‘Intern’ are clearly communicated to the public.

That the profession is made aware of examples of acceptable and unacceptable use of titles. For example,

‘professional interest’ – in a particular field is acceptable
‘particular interest’ – acceptable
‘non-specialist’ – a negative title and uses the ‘s’ word and thus unacceptable
term ‘cat vet’ – acceptable
‘cat expert’ or ‘special interest in cats’ – unacceptable
the suffix ‘ist’ is acceptable for those who do not deal directly with the public (e.g. pathologist)
‘ist’ is not acceptable for those who deal directly with the public unless the vet has specialist registration—
g. ’acupuncturist’
“consultant to” is acceptable
“consultant in” a particular field implies specialisation and is not acceptable

Again from my own perspective I think this goes too far and unfairly limits those who are bona fide experts in fields that have some crossover with veterinary medicine but that are not exclusively veterinary medical fields. I sense there's a reasonable, workable middle-ground here that could be adopted though.

RE: Certificate holders offering referral services

jd2008 — Wed, 12 Jan 2022 02:24:58 GMT

I agree and I don't, to some extent. Your example of TPLO is a a good one and having access to a cheaper option will mean that, potentially more animals can benefit. On the other hand, though, if more owners choose this option to save some money (but could afford Specialist referral if cert holder wasn't an option), more animals are at risk of suboptimal outcome.

Is there a point where we have too many in this middle tier, crowding out the most competent?

RE: Certificate holders offering referral services

Michael Woodhouse — Wed, 12 Jan 2022 00:43:30 GMT

[quote userid="9239" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30144/certificate-holders-offering-referral-services/235069#235069"]A good certificate holder can do a TPLO for 2000 pounds and some owners can afford that but may not afford 3500-4000 for the same surgery. [/quote]

Or to stir the pot further, a lateral suture in house still has good outcomes and is as quick as a bitch spay. Last time I looked the outcome measurements weren't that much worse, for a fraction of the cost. If young and expensive then push for referral, but most clients not insured so rare for one to go anywhere else.

Like with everything, it's about informed consent and money. I see no fundamental problem with certificate holders taking referrals if the owner knows what they are getting in terms of cost and experience. No different to passing a case onto a colleague who has an interest in a particular area. I'd have thought in the days of experienced omnicompetent vets the middle tier was less needed, but as vets deskill then maybe needed more than ever? I'll fight tooth and nail that any vet should be allowed to do anything they can do with competence. In my opinion nothing should ever be 'specialist only'.

If your practice is sending a lot of cases to a particular service then I'd take that as a kick up the backside to do some CPD and maybe invest in equipment so you can handle more of those cases in house. The variety makes the job interesting.

RE: Certificate holders offering referral services

Dinu Catilina — Wed, 12 Jan 2022 00:00:24 GMT

A very fair concern and I had similar thoughts recently. If we refer to a referral centre then the expectation from the client is to see a specialist and unfortunately especially in one particular centre they are being seen by certificate holders or not even that. Now, I don't express judgement on their skills, they are probably better than me if they work there but I also think it's not fair, the client is charged the same as seeing a specialist.

This being said, I believe there is a place for a referral practice that it's not a specialist centre. Some people want to see someone more qualified than a GP but can't afford a specialist. A good certificate holder can do a TPLO for 2000 pounds and some owners can afford that but may not afford 3500-4000 for the same surgery. These places are not a replacement for specialist services but there is a place for them in the market.