Do you follow referral centre recommendations?

RE: Do you follow referral centre recommendations?

David Mills — Sun, 08 Sep 2024 14:45:29 GMT

[quote userid="4122" url="~/f/clinical-questions/31023/do-you-follow-referral-centre-recommendations/245451#245451"]Not “bloods normal” or on the infuriatingly unrecorded separate lab machine or commercial lab record [/quote]

Sorry can't let this slide

As if 99%+ of bloods aren't re re run at the referral centre anyway.

One cardiologist I know said to me "yeah we'll do bloods because it's expected and gives you time to think"

RE: Do you follow referral centre recommendations?

Mark Patteson — Sun, 08 Sep 2024 09:01:47 GMT

As ever this is down to communication. The better this is both ways -The better the outcome for the patient and client. Busy lives make this difficult but good systems help. Ideally a personal work email that cuts out reception not passing on messages. And I would happily talk to a worried referring vet at 8 pm on a mobile if I had a number for them. They can call me too
if a primary vet is uncertain about a recommendation maybe they actually spotted an error - so if they ask - good for them.

Likewise the more information a referral vet gets the better. Not press F6 sends 200 pages of size 4 font vaccine get out clauses and dog food orders. But vital stuff like the more recent blood results. Not “bloods normal” or on the infuriatingly unrecorded separate lab machine or commercial lab record

and cases change. Especially medical ones. Things may happen that aren’t expected so a the primary vet should certainly ask if they think something isn’t right.

it’s a two way process and communication builds trust both ways which is essential for the best outcome

RE: Do you follow referral centre recommendations?

Francisco Gomez — Fri, 06 Sep 2024 21:41:16 GMT

If I were Michael referral vet, I'd appreciate this information. It might give me the chance to consider this and update my practice or the chance to explain my rationale.

Knowledge doesn't need to be a one-way street.

RE: Do you follow referral centre recommendations?

Lucy Fleming — Thu, 05 Sep 2024 09:32:18 GMT

Interestingly, the ACVIM consensus statement for use of gastroprotectants suggests that use of omeprazole alongside NSAIDs, rather than decreasing the risk of NSAID-related injury, might actually increase it due to dysbiosis associated with the omeprazole use...

"Bacterial overgrowth can have deleterious consequences when PPIs are administered with other drugs that can injure the small intestinal (SI) mucosa.94 It is common to prescribe PPIs in patients at risk for upper GI injury from nonsteroidal anti-inflammatory drugs (NSAIDs), but PPIs can alter the SI microbiome, increasing the risk of injury to the intestinal epithelium caused by NSAIDs. This effect is acid-independent and unrelated to gastric mucosa injury caused by NSAIDs. Inhibition of intestinal cyclooxygenase 1 and 2 (COX-1, COX-2) enzymes injures the SI mucosa. Enterohepatic recycling of NSAIDs likely plays a role whereby high concentrations of NSAIDs in bile are secreted into the duodenum in close proximity to the major duodenal papilla. Some of the most serious intestinal lesions in dogs caused by NSAIDs occur in this region.10, 95, 96 Small intestinal injury may be caused by increased numbers of gram-negative facultative anaerobic bacteria that flourish in the SI of patients treated with PPIs. Lesions are characterized by loss of villi, erosions, and multifocal ulcers distributed throughout the small bowel. Anemia also may occur. Whereas some bacteria play a protective role against intestinal mucosal injury by NSAIDs, the intestinal dysbiosis arising from PPI administration increases the risk of NSAID-induced intestinal injury"

So, I'd say that's a starting point for defending it, at least!

RE: Do you follow referral centre recommendations?

Clive Ansell — Sat, 31 Aug 2024 19:15:40 GMT

My take on this, is that once I have referred a patient the referral clinician is in charge of the case until it has been discharged from his or her care.

I tend to follow their advice and instructions, and cannot think of a single occasion where I would not. If I or the client have concerns I will call or email my referral colleague and discuss. I consider their knowledge is likely better than mine, and that they are likey to be more up to date with the latest opinion, literature and research in their chosen area of expertise.

In Michael's example of omeprazole, I would just go along with it; on the basis it is unlikely to do any harm, although I almost never use it myself and feel it is overrated and overused. (it makes me feel really ill and nauseous if I take it). In the very rare event that case a develops a gastric bleed and complications following withdrawal after being prescribed by a referral clinician, how would one explain or defend it? could be a tricky one.

RE: Do you follow referral centre recommendations?

cairncross — Sat, 31 Aug 2024 16:51:37 GMT

probably didn't refer, mostly things appear back here having been for a "referal" that we knew nothing about there may have been an email somewhere in the ether that we didnt pick up there might not . of course we should communicate but the reality isn''t there . i am doing 14 h day i am picking up on some communications when i am eating , when i am in the bathroom when i am driving home on hands free but i probably only answer 10 percent of those i should

We would have 100-200 remote contacts per day that should get some sort of vet input and response email text phone call messenger or some other app very few do . essentially you are going to have to que up an see the vet in person here we are all working more hours than we should just triaging and dealing with those cases which appear physically in front of us . there was a q from 7am this morning and will be monday to friday people starting just before 7am to wait for the doors to open at 9 am. LOCAL GP surgery is the same though they tell me requests for contact are in the range of 700 plus per day . We sold out of vaccines this am , we have ran out of various meds in the last weeks with staff having to do runs to the wholesalers for essentials largely unheard of for us but we are not remotely keeping up with demand just triaging the immediately sick or injured .

RE: Do you follow referral centre recommendations?

Beats — Sat, 31 Aug 2024 12:50:59 GMT

I think it would depend if I am providing care now or the other vet is. I would advise to seek advice from the other vet incase of a surgery or ongoing medical condition and would not throw my own opinion into the mix if is not my case. Ask 2 vets get 3 opinions and all that. If somehow I am now the vet for the dog I would try to not interfere with any parts of the dog being treated by another vet and direct them to discuss that part of the dog with that vet rather than me. If I somehow inherited a case from another vet that was going to be taking it back I would try to do as they would want done assuming it was anticipated that they would be taking care back again in a reasonable timeframe otherwise I would just offer my own advice.

It is rare in this neck of the woods that this crops up. Couple of months ago did remove a sock from a dog that had lost a kg on a diet of venison and tapioca that another vet had advised. This appeared to be an exclusion diet and I directed to speak to the other vet as while I personally thought it was a detrimental course of action I would also find it annoying if I was doing some fancy exclusion diet and another vet stopped it on me.

RE: Do you follow referral centre recommendations?

Alasdair Hotston Moore — Sat, 31 Aug 2024 10:13:13 GMT

[quote userid="3169" url="~/f/clinical-questions/31023/do-you-follow-referral-centre-recommendations/245418#245418"]One of the vets at a local referral centre sends everything home on omeprazole with NSAIDs and the first thing I do when I see them back is stop that, and I don't ask 'permission'.[/quote]

Because you think your knowledge trumps their's? In which case why refer in the first place?

That sounds a but harsh, hard to imply subtlety in a. short message, sorry

RE: Do you follow referral centre recommendations?

Michael Woodhouse — Fri, 30 Aug 2024 23:13:13 GMT

[quote userid="8991" url="~/f/clinical-questions/31023/do-you-follow-referral-centre-recommendations"]

What do you do?

[/quote]

What I see fit. It's medical advice, like any advice you are given, you can choose to follow it, or ignore it.

In the two initial examples, I would happily ignore it and do as I thought appropriate. I have no reason in those cases to speak to the person making such recommendations. The only time I would make contact (or attempt to) was if there was a specific post op requirement that didn't make sense or seemed too restrictive or impractical.

One of the vets at a local referral centre sends everything home on omeprazole with NSAIDs and the first thing I do when I see them back is stop that, and I don't ask 'permission'.

RE: Do you follow referral centre recommendations?

cairncross — Fri, 30 Aug 2024 20:02:44 GMT

I don't know when I last had the time to discuss a case with a referral clinician or when they had time to discuss with me not when the returning client could afford any if the recommended ongoing care .

RE: Do you follow referral centre recommendations?

Francisco Gomez — Fri, 30 Aug 2024 16:18:15 GMT

A very large part of my referral work is communicating with the first opinion vets for ongoing care.

Unfortunately vets are super overworked and too busy and can barely attend the phone. Then, often part of the message gets lost.

It's also difficult to address their experience level. No disrespect. I don't want to write the same letter to a new graduate than the letter I write to an experienced vet. All these can often be addressed in a 5 min phone call.

RE: Do you follow referral centre recommendations?

David Mills — Fri, 30 Aug 2024 09:15:47 GMT

These weren't my cases, but just came up in a discussion as there is often an owner caught in between and owners may feel more comfortable speaking openly with their regular vet (esp around costs and revisits etc). I think it is particularly difficult when one's view may align somewhat with the owner's and there is a risk of over-treatment.

I'm not sure how often this comes up which is why I posed the question. I guess the crux is where responsibility lies - are first opinion vets there to carry out instructions and suspend their own judgement? Or check everything first? Of course speaking with the clinicians is (I assume) normally carried out but if this is flipped back onto the first opinion vet ("this is what we would advise but it's your judgement") what then?

RE: Do you follow referral centre recommendations?

Alasdair Hotston Moore — Fri, 30 Aug 2024 07:25:31 GMT

It’s an awkward situation best resolved by discussion.

Two thoughts though

Referral is referral: you have assigned responsibility to another clinician. This is not the same as secon opinion (this used to be explicit in the GPC, I haven’t looked recently)

Secondly, you would not expect a referral clinician to undermine your prior work. Take care you dont do the same for them. And if you disagree more than once, sounds like you need to find another referral colleague

RE: Do you follow referral centre recommendations?

Andy Moores — Thu, 29 Aug 2024 10:05:30 GMT

Surely the right answer is not to follow or not follow the instructions, but to discuss with the referral clincian involved if there is any concern about the advised treatment?