Are the days of referral practice numbered?

RE: Are the days of referral practice numbered?

J G Wray — Sat, 15 Oct 2016 23:59:28 GMT

[quote user="rhmrcvs"]

I despise the title vet gp .... My opinion is lots gets referred through fear of being unable to undertake investigation , surgery etc , some through lazyitis/ can't be arsed , Where has the term vet gp come from ??

[/quote]

Well, our practice is called GPVets and I have no problem about the term GP vet. Not sure I have much fear, nor do I see it in my colleagues, all of whom have more than twenty five years in the job and not sure any are lazy given that they turnover ~£300,000 per FTE and yet we refer cases, because we recognise our limitations and when there needs to be other input into the lifetime of care we are aiming to provide

Referral practice takes up a small part of a few of our patients' lives and in my view, expressed in thebeginning of this thread, a reducing amount as we cherry pick the acquisition of skills.

RE: Are the days of referral practice numbered?

rhmrcvs — Sat, 15 Oct 2016 20:05:11 GMT

I despise the title vet gp because it gives the impression we are like human GPS who do very little. The reason I chose veterinary medicine not medicine is the huge variety , we can do orthopaedics one day , internal medicine etc the next. My opinion is lots gets referred through fear of being unable to undertake investigation , surgery etc , some through lazyitis/ can't be arsed , in particular Fri evenings. Where has the term vet gp come from ??

RE: Are the days of referral practice numbered?

Martin Atkinson — Fri, 14 Oct 2016 18:58:37 GMT

[quote user="bevs2251"]Expected to run full blood profile before giving an injection of NSAID these days. [/quote]A case in point today: elderly cat with stomatitis not eaten for 6 days needed some pain relief before we could get him in for a dental and I wanted to do a renal profile. I've seen enough young healthy cats go into renal failure from one shot of meloxicam to be happy about not checking out an at-risk one. But the owner couldn't/wouldn't afford a pre-surgical blood profile. Cat was a lot happier and ate for England with just one shot of carprofen but owner has been warned she's taking a risk.

[quote user="bevs2251"]I never give an NSAID pre-op, always post-op (& not if there has been +++ bleeding, nor for dentals). [/quote]I generally don't but had little choice with this cat and if in doubt they also get 40-60 ml fluid sub-cut even if they're not dehydrated.

RE: Are the days of referral practice numbered?

bevs2251 — Fri, 14 Oct 2016 06:04:31 GMT

Expected to run full blood profile before giving an injection of NSAID these days. Although, to be fair, there have been rare cases where young animals have gone into renal failure after just one NSAID dose (even when on fluids with GA - not sure if preGA bloods done in the case I know about). I never give an NSAID pre-op, always post-op (& not if there has been +++ bleeding, nor for dentals).

Re: Are the days of referral practice numbered?

Alex Gough — Wed, 06 May 2015 18:50:52 GMT

Are you implying that I'm not romantic, JGW? But I agreed with Arlo and Andrew! Would flowers help?

Re: Are the days of referral practice numbered?

J G Wray — Wed, 06 May 2015 07:24:48 GMT

[quote user="Arlo Guthrie"]

Either way, I agree with Andy wholeheartedly:

[quote user="Andrew Kent"]I still feel quite saddened when I read this forum that there is a continued feeling of us and them and an attitude that referral practitioners are somehow out to do primary practitioners down or just make money etc.[/quote]

and think it would be more constructive to focus only on how the relationship between referral practitioners and GPvets can be improved, rather than highlighting differences in a way that seems slightly pejorative.

[quote user="Andrew Kent"]I see it as us sharing a common goal to do the best of our clients - I hope that this is how practitioners who refer to me see it and certainly that has always been my aim. It is a huge responsibility to (as JGW says) borrow the trust that exists between the client and vet - anybody who doesn't respect that should not be in referral practice.[/quote]

[/quote]

I see you and Dr Kent as romantics. Dr Kent is easier to understand because he works in a centre affiliated to a veterinary school, where purpose and aims are very different from, say , Dr Gough's setup.

Re: Are the days of referral practice numbered?

J G Wray — Wed, 06 May 2015 07:20:59 GMT

[quote user="grumpyoldman"]I had an interesting conversation with my youngest son recently ,after a letter from a referral centre appeared offering to buy our practice. They were a stand alone referral centre ,massive investment etc Who were obviously being strangled by the movement of some larger corporate empires into the second tier and shipping their referral work accordingly. They were seeking to buy practices in their primary referral zone. Probably to stabalise and increase their referral input . Money aside : they seemed to want to take all our interesting surgery away leaving us squeezing anal glands etc ,not a happy prospect .[/quote]

What a very expensive way of sustaining a referral centre. If the money is adequately obscene then why not take it bank it for a couple of years then buy the shell of your former practice back for a song in three or four year's time when it becomes a financial millstone? You could then build it up again and...

There is the whiff of a morally corrupt mind at work here, where the intention is to de skill your colleagues, remove their autonomy and realign their purpose to become functionaries. Removing autonomy mastery and purpose at a stroke removes the motivators for those working in any place. There will only be employees who need the money operating a system akin to the budget service providers that have emerged in recent years.

Even Corporates with their hub and spoke systems have trouble supporting their referral centres. They know that they can't treat their colleagues with this level of contempt and retain well motivated productive staff. The corollary of this is that their referral centres are more pragmatic already.

Anecdote:

I asked a referral orthopaedic surgeon the other day about a competitor's sales pitch of a lifetime guarantee and was treated to a list of their competitor's technical shortcomings. Guess who got the referral?

Re: Are the days of referral practice numbered?

Arlo Guthrie — Wed, 06 May 2015 07:16:09 GMT

[quote user="J G Wray"]

[quote user="Arlo Guthrie"]Surely the impact of something on society is a factor of both volume and impact. GPs see more patients and build longer term relationships. Referral practitioners may see fewer patients, but are likely to have a more profound impact on them. [/quote]

Well, not in Our World for a number of reasons.

Firstly, there a thousands more GPVets than referral vets. There is the reverse in the NHS[/quote]

How fascinating - I would never have thought there were more specialist Drs than GPs.

[quote user="J G Wray"]Secondly, Vet GPs form a dispersed network of access for the public to their services. They are what the public experiences when it comes to veterinary care. They are the face of the profession for society and their impact is therefore greater.[/quote]

Agree

[quote user="J G Wray"]Thirdly, there's cost. The NHS has, in theory, free access to all at the point of provision. GPVets cannot deny some form of care to all animals. Referral practices have a barrier through cost. They are selective in their impact.[/quote]

Agree

BUT, I think you've moved the goalposts somewhat! What I took issue with was your statement that referral practices have little to do with society.

To me, that belittles the contribution that referral practitioners make, and seems to take no account of the fact that those who specialise will usually have a greater impact on the (albeit fewer) patients/owners they see, contribute more to the overall sum of scientific understanding, teach GPs and (because of the greater inherent interest in cutting edge stuff) often act as ambassadors for the profession.

I'm being pedantic, but I would have agreed with you if you'd said 'Referral practice has less to do with society than general practice'. It was the word 'little' I took issue with.

Either way, I agree with Andy wholeheartedly:

Re: Are the days of referral practice numbered?

grumpyoldman — Wed, 06 May 2015 00:06:41 GMT

I had an interesting conversation with my youngest son recently ,after a letter from a referral centre appeared offering to buy our practice. They were a stand alone referral centre ,massive investment etc Who were obviously being strangled by the movement of some larger corporate empires into the second tier and shipping their referral work accordingly. They were seeking to buy practices in their primary referral zone. Probably to stabalise and increase their referral input . Money aside : they seemed to want to take all our interesting surgery away leaving us squeezing anal glands etc ,not a happy prospect .

When we think about money is it better to offer the 80%(none insured low wages) who cannot afford a referral a Myelogram and a hemi-laminectomy with an 80% chance of success for £1500, or a 90% chance of success for £5000 with a referral, that only the top 20% only can afford, or a body bag because we are scared of doing it?.

Referral culture raised standards at the top ,but it also simultaneously reduced skills in the middle. The people in the middle who were always prepared to do things are now emerging as a middle tier of expertise often with decades of experience to back it up .

Re: Are the days of referral practice numbered?

J G Wray — Tue, 05 May 2015 18:12:03 GMT

Well, not in Our World for a number of reasons.

Firstly, there a thousands more GPVets than referral vets. There is the reverse in the NHS where doctors work in vertically organised colonies called hospitals in the main and GPs are only 24-25%

http://www.gmc-uk.org/doctors/register/search_stats.asp

So, in Our World VetGPs have the main impact on animal welfare, far outweighing any other veterinary contribution.

Secondly, Vet GPs form a dispersed network of access for the public to their services. They are what the public experiences when it comes to veterinary care. They are the face of the profession for society and their impact is therefore greater. Then as you say they also develop this public epxerience across generations of clients, and preserve it across decades of changes in society. Referral practices operate in small colonies, interact with society under controlled conditions and have only been here for the blink of an eye.

Thirdly, there's cost. The NHS has, in theory, free access to all at the point of provision. GPVets cannot deny some form of care to all animals. Referral practices have a barrier through cost. They are selective in their impact.

It does not serve to look at Vet GPs and NHS GPs as being equivalent creatures. Referral practices in Our World also don't have an absolute equivalent in the human world, but it may be coming..

[quote user="Arlo Guthrie"]As I say, I think you raise all sorts of interesting points, I just think the divisive way that some are framed is a bit unfortunate and not necessarily all that constructive.[/quote]

I'm not trying to sell anything or move anyone. I just asked a question is all

Re: Are the days of referral practice numbered?

Arlo Guthrie — Tue, 05 May 2015 09:42:51 GMT

[quote user="alex gough"]but it's fewer rather than less patients[/quote]

What was I thinking??!

Re: Are the days of referral practice numbered?

Alex Gough — Tue, 05 May 2015 09:36:49 GMT

I agree with much of what you say, Arlo, but it's fewer rather than less patients. Unless you are measuring them by total weight.

Sorry, couldn't resist.

Re: Are the days of referral practice numbered?

Arlo Guthrie — Tue, 05 May 2015 09:17:11 GMT

Must say, one of the more interesting discussion points. But ...

[quote user="J G Wray"]your [referral] practice having little to do with society[/quote]

To me, this reads as a bit of an unnecessary poke. In any event, I don't personally think it's true.

My dog hasn't yet needed to be referred, so I don't have any experience in the veterinary context. But I certainly have in a medical sense, having been referred to two different specialists for some pretty major spinal surgery (years ago).

Do I think the relationship I had with the specialist was less important than the one with my GP, or that they were somehow a less important or less significant contributor to society? No. Certainly not. Arguably the reverse. I go to the GP for a sniffle. I pick a GP (partly) because I have confidence that they will 'refer well.' The relationship, trust and faith I had in a specialist was arguably more important because they were dealing with something that had far bigger consequences for me than a sniffle.

Surely the impact of something on society is a factor of both volume and impact. GPs see more patients and build longer term relationships. Referral practitioners may see fewer patients, but are likely to have a more profound impact on them.

And of course, there are those referral practitioners who, through their work advancing scientific understanding, training GPvets and sometimes through their exposure in the media (Noel Fitzpatrick being the current case in point), are even bigger contributors to society.

As I say, I think you raise all sorts of interesting points, I just think the divisive way that some are framed is a bit unfortunate and not necessarily all that constructive.

Re: Are the days of referral practice numbered?

J G Wray — Tue, 05 May 2015 07:28:05 GMT

[quote user="alex gough"]I'm arguing that it dilutes the part of the certificate that is involved in the clinical aspects of the discipline[/quote]

Herein lies a misunderstanding of the purpose of the Cert AVP. RCVS designed them, with large amounts of academic input, to be more than clinical, so that qualification is acquired in a profesional framework rather than exclusively clinical. RCVS have a remit to protect society/the public and they saw a balance requirement in gaining their qualification, which was hitherto absent. If your estimation of the value of further qualification excludes the necessity of this balance, because it is of little use in your practice, your practice having little to do with society, then you will see little merit. On the other hand...

There may also be a misunderstanding of why vets do CPD and further qualifications. They do it/them for themselves primarily, not to meet some regulatory target and once knowledge is acquired they leverage it, by broadening the services they can offer and contribute to their business model. This is the reduction in assymatery I was talking about. It is not likely to be a popular move with referral practices, because it changes the traditional dynamic existing between primary and referral practice, particularly if the referral vets see this leveraging coming from an "illegitimate", insufficiently knowledgable premise.

However, referral practice relies on primary practice and has the choice of adapting or not. Leveraging additional services is part of the new offering from primary practitioners and ain't going away. Retreating into an ever more esoteric existence in referrals and expecting persistence of business is truly a flawed premise.

Re: Are the days of referral practice numbered?

Michael Woodhouse — Mon, 04 May 2015 20:39:04 GMT

[quote user="alex gough"]Out of interest, does anyone know if the number of certificate holders qualifying (as opposed to registering for) the new certificates, is higher on an annual basis than the old style certs? It isn't easy to see on the RCVS website. [/quote]

There was a frequently quoted 80% drop out rate on the old certs - although I can't find hard stats to back that up

http://www.vetsonline.com/media/204/c2dca8cef81d97528a802f73d8537.pdf

Currently 18% of those registered for the Cert AVP hold the qualification, but it is relatively new and you have 10 years to complete.

2014 - 230 with Cert AVP (+104)

2013 - 126 with the Cert AVP (+60)

2012 - 66 with Cert AVP

I'm sure you are going to see a big jump when the 2015 figures are published.

Re: Are the days of referral practice numbered?

Alex Gough — Mon, 04 May 2015 19:48:21 GMT

[quote user="Michael Woodhouse"]Then that is through ignorance of what the CertAVP contains. I actually enjoyed the A module and it did make me think far more about my own learning and some very important areas of veterinary practice. I agree it was initially off-putting, but once I got into it I found it very valuable.[/quote]

I'm not arguing its not valuable, I'm arguing that it dilutes the part of the certificate that is involved in the clinical aspects of the discipline. Unless you believe that the CertAVP requires more time/effort/work than the previous certificate, then inevitably if you add a large extra something into the course and exam (module A), then you must lose some other aspects (the clinical parts). So if we compare the BSAVA certs, they have 60 academic credits devoted purely to the discipline you are studying, whereas the CertAVP has some of those academic credits devoted the "softer skills" as you call them. Remember, we are arguing about whether CertAVPs will affect referrals. If there is a big uptake of CertAVPs, then you may be right that fewer cases will get referred, but not necessarily that there will be more referral practitioners. Although I do know vets who take referrals on the basis of their CertAVPs.

I am puzzled why, if the RCVS think the module A skills are so important that old style certificate holders have to do an extra 100 hours study over the next 5 years to prove competency for the advanced practitioner status, why diploma holders aren't held to the same criteria. As far as I can tell, there is no equivalent of module A in the diploma.

Out of interest, does anyone know if the number of certificate holders qualifying (as opposed to registering for) the new certificates, is higher on an annual basis than the old style certs? It isn't easy to see on the RCVS website.

Alex

Re: Are the days of referral practice numbered?

Michael Woodhouse — Mon, 04 May 2015 19:25:58 GMT

[quote user="alex gough"]Because of the requirement for module A, with its emphasis on things like health and safety, learning skills, professional conduct etc, there is less time and emphasis on the individual disciplines, so the qualification is less highly regarded in some quarters when it comes to a particular discipline.[/quote]

Then that is through ignorance of what the CertAVP contains. I actually enjoyed the A module and it did make me think far more about my own learning and some very important areas of veterinary practice. I agree it was initially off-putting, but once I got into it I found it very valuable.

The addition of the softer skills doesn't somehow make the certificate any smaller. The three case reports of 3000 words in the old cert gives 9000 words. The A module takes up 10,000 words. The remaining ~50,000 words are clinical, and 40,000 words more than the old cert. There is far more literature searched and referenced. The final synoptic examination gives final assurance that the practitioner has reached the required level.

[quote user="alex gough"]That is different from saying old style cert holders know more about their subject than new style, but it is likely to have been tested to a higher level[/quote]

Again - I simply don't agree. RCVS actually are treating the old certs as less than the new CertAVP as the soft skills are a requirement for advanced practitioner.

[quote user="alex gough"]I believe BSAVA brought out their more academic certificates because of a perceived deficiency in the CertAVPs. [/quote]

I won't put words in BSAVAs mouth, but they are also worth 60 points at level 7. They are no more academic, but don't have an off putting soft skills module.

It's like when the new cohort get their A level results and everyone cries out that they are getting easier. Just accept they are different routes to the same end. I think it is wrong to suggest that an old or new cert is more or less worthy than each other.

[quote user="alex gough"]I'm sure it's a valuable exam, but the comment was in relation to all the CertAVPs who would now be doing referrals[/quote]

I'm not aware of any CertAVP guys using that qualification alone to take referrals, but I do believe the process will allow these guys to gain confidence and experience and tackle more cases in practice than they would have previously. That means less cases need referring on.

Re: Are the days of referral practice numbered?

Anthony Todd — Mon, 04 May 2015 18:43:54 GMT

[quote user="Andrew Kent"]but we see many more cases that need specific procedures - endoscopy, bone marrow, stenting etc.[/quote]

Exactly as I expected 'cos of what you can do, not what you know!

As it should be, the days of doing a cruciate "to keep your hand in" are, fortunately, gone.

Re: Are the days of referral practice numbered?

Hannah Wynne Richards — Mon, 04 May 2015 17:47:31 GMT

Not so much a deficiency as the fact that many employed veterinary surgeons are positively antagonistic to any business aspects of practice.

When it comes to difficult clients, my impression is that 1st opinion and referral practitioners have about the same% , but they're a different difficult type. We have more of the unwilling to pay type, they have more clients, who having paid for a referral expect miracles, which aren't always possible.

Wynne

Re: Are the days of referral practice numbered?

Alex Gough — Mon, 04 May 2015 13:57:04 GMT

[quote user="Michael Woodhouse"]Alex, I thought better of you. I can't let that comment pass without comment.[/quote]

Apologies to CertAVP holders. I'm sure it's a valuable exam, but the comment was in relation to all the CertAVPs who would now be doing referrals. Because of the requirement for module A, with its emphasis on things like health and safety, learning skills, professional conduct etc, there is less time and emphasis on the individual disciplines, so the qualification is less highly regarded in some quarters when it comes to a particular discipline. That is different from saying old style cert holders know more about their subject than new style, but it is likely to have been tested to a higher level. I believe BSAVA brought out their more academic certificates because of a perceived deficiency in the CertAVPs.

Re: Are the days of referral practice numbered?

Michael Woodhouse — Mon, 04 May 2015 13:45:49 GMT

[quote user="alex gough"]The CertAVP is quite a watered down version of the older certificates, and I know a lot of vets who start them and get disillusioned with certain aspects of the new format, and give up.[/quote]

Alex, I thought better of you. I can't let that comment pass without comment.

I can only speak for the cattle certificate, because that is all I have the information for. To get a certCHP you needed 3 case reports do 2 written exams and an oral/practical exam. To get the CertAVP I had to do 14 case reports, critique 3 papers, 2 herd health plans, learning diaries and the full A module. My body of work was somewhere between 50,000-60,000 words. Then I had to do the synoptic oral exam in the same vein as the old certs.I'm absolutely convinced I could have gained an old style cert with a damn sight easier than getting a CertAVP.........

I understand the criticism of the old certs was varying standards across the subject areas. I also understand there was a degree of 'pulling up the ladder from above' and the guys setting the exams (who had the qualification) making it harder to achieve. Now the standards are equal across the board and the qualification is allied to the standard framework. A CertAVP in exotics is worth the same as one in sheep or medicine etc... There is growing flexibility to continue study and build the work into masters degrees or even doctorates. I think it is a real leap forwards in postgraduate veterinary education.

Re: Are the days of referral practice numbered?

Anthony Todd — Mon, 04 May 2015 13:26:03 GMT

[quote user="alex gough"] And they are no more client led than surgical referrals I dont think. [/quote]

Sorry, don't get this?

Would the introduction of an "intern" or "houseman" sort of system work in Vet. practice?

I'd done 1, that's one, bovine rectal when I graduated in 1961 in a class of about 25 and I went straight into the most intensive dairy area in the world [argued the locals...]

Somehow new grads need pre-graduation experience or confidence before they are paid to be judged by an ever more critical and informed public backed by the uneconomics, but persistence, of of insurance, let alone the cloud of negligence hovering over each consultation.

Otherwise I can see the GP vet just referring anything and almost everything to the "specialist" nearest to the symptoms described by the owner.

Can't risk taking a guess these days, however well informed.

Re: Are the days of referral practice numbered?

Alex Gough — Mon, 04 May 2015 13:12:48 GMT

[quote user="J G Wray"]I'm struggling with this notion because all these cases start off in first opinion practice. Are you saying that the first opinion vets refer for euthanasia?[/quote]

No I'm saying the prognosis for these cases is on average worse than in first opinion practice, and so euthanasia will be more frequent.

[quote user="J G Wray"]I get internal (diagnostic) referrals all the time from colleagues [/quote]

If by internal you mean from within your own practice, then that is not the same. Your earlier experience working in a referral practice for 5 years may be more relevant, depending how far back into the last century you go! Things have certainly changed in referral practice just in this century.

[quote user="J G Wray"]

In a business sense I think so - referral practice are, naively, becoming more esoteric. There is a narrowing in respect of knowledge etc, and to return to my original premise, I can't see how referral practice as it is set up now is a sustainable business model. It needs to evolve in light of competition for a limited market and the gateway to that market, commoditisation of services, resolution of knowledge and skills assymetry, diagnostic dogma (repetition and soaking up of funding) and, ere long pressure from funders.

[/quote]

I'm largely in agreement with you here, although it may already be evolving.

[quote user="J G Wray"]Do you do anything like this or is your business plan for the next three years predicated on no change in the referral model?[/quote]

Yes we do what ifs to some extent, although dealing with what is, is time consuming enough.

Your analysis of difficult clients was an interesting exercise, one I've not thought to do. My definition of difficult clients was more subjective than yours but not far away.

[quote user="J G Wray"]Do you or your colleagues have any desire to find out? [/quote]

I can't speak for my colleagues, but no, not a huge desire. If I was getting a lot of complaints from clients, then maybe it would be more a useful exercise. Though I would probably be sceptical of the results anyway!

Re: Are the days of referral practice numbered?

J G Wray — Mon, 04 May 2015 12:25:55 GMT

[quote user="alex gough"]

[quote user="J G Wray"]You misunderstand the meaning of a bonded client.[/quote]

No I don't.

[/quote]

What is your defintion of a bonded client, as opposed to , say, an active client?

[quote user="alex gough"] In fact since many medical referrals are emergencies or much sicker than routine cases seen in first opinion practice, you could answer that actually this is more commonplace.[/quote]

I'm struggling with this notion because all these cases start off in first opinion practice. Are you saying that the first opinion vets refer for euthanasia?

[quote user="alex gough"]You never confirmed whether you had worked in referral practice,[/quote]

I get internal (diagnostic) referrals all the time from colleagues and worked in a nascent referral practice for five years back in the last century.

[quote user="alex gough"]Do you agree in light of my earlier post that referral practices and first opinion practices are getting further apart?[/quote]

Have you done any what ifs? We did three not so long ago as I've previously mentioned on another thread. The first was, what if we lose the privilege to dispense? The second was what if a well marketed competitor set up just down the road and took 25% of our active clients? The third, what if we needed to double turnover in a year?

Do you do anything like this or is your business plan for the next three years predicated on no change in the referral model?

[quote user="alex gough"]I mentioned your assertion to one of our first opinion vets working in our hospital that we don't regularly deal with difficult clients and she laughed her head off![/quote]

Hmm. We have had a look at what we call "difficult clients" and their attributes. The two largest attributes and these were shared by some clients creating an amplification of effect, were cost questioning clients and time consuming clients. We dealt with the time consuming clients by resolving our own attitudes to time usage and communication first, leaving a few who were dealt with by procedural changes. That left the cost questioners. We broke these down into approximately 8-10% of clients who were cost questioners and a much smaller number, 2-3% cost rejectors. Then we worked on managing these in consult and front desk, as in what we say and do. We worked on the cost rejectors, mainly by pointing out to ourselves that if we need to charge what we do then we should expect this and relax. Is your defintion of "difficult clients" different?

[quote user="alex gough"]I have no objective criteria to score myself.[/quote]

Do you or your colleagues have any desire to find out? A world of psychometric testing and analysis awaits in order to know thyself. BVA have bought into this with last week's VR stuff on career identity, run by people not a million miles from you so why not? I happen to think this is a rhetorical question, by the way.

Re: Are the days of referral practice numbered?

No Name — Mon, 04 May 2015 12:12:45 GMT

[quote user="Michael Woodhouse"]

And why is that? Who's 'fault' is it? Basic orthopaedic work isn't hard, if you follow the principals and invest in some kit. A lateral suture is technically easier that a bitch spay - there is no reason that it shouldn't be in a new grads repertoire as a day one skill - although I can see reluctance from the universities

[/quote]

Performing a bitch spay isn't part of our day one skills, nor is orthopaedic surgery so the unis don't need to teach us these things. I've not done small animal rotations yet, but so far I felt that the teaching I've received on farm has been excellent and very hands on. HOWEVER, quite a lot of the time I feel we could benefit from more patients to practise on.... and I'm in a group of only 4 whereas other unis have up to 8 per rotation group! EMS can plug some skill gaps but can be so variable.