Lessons from a GP (Human)

RE: Lessons from a GP (Human)

Rob Loxley — Sat, 08 Jul 2017 22:05:35 GMT

[quote user="Matthew Plumtree"] I calculated if I could get all our registered clients paying approximately £23 a month I could run the practice's services "for free" at point of care, NHS-style. Not sure that's feasible, though wouldn't it be lovely take the cost discussion out of the consultation?![/quote]

How does the PDSA Petaid scheme work?

RE: Lessons from a GP (Human)

Anthony Todd — Sat, 08 Jul 2017 10:53:33 GMT

[quote user="Rob Davis"]recommending histopath[/quote]

Apart from being [arguably] "gold standard" it's also, I suggest, another defensive add-on in this legal age in that, should the un-histoed "lipoma" regrow and there was no histo back-up to confirm the diagnosis, the vet might be in trouble.

This defensive veterinary practice is a recent development IMHO.

Is this so??

RE: Lessons from a GP (Human)

Rob Davis — Sat, 08 Jul 2017 10:19:24 GMT

[quote user="Matthew Plumtree"]Perhaps one could do a scheme and then offer add-ons for electives, e.g. if the owner REALLY wanted the in-all-probability-a-lipoma mass sent off. It would depend on the values of the staff involved, and one would hope that, as veterinary professionals, we would act ethically[/quote]

I think it would require very clearly stated guidelines and some sort of contract. I also think, as suggested previously, that the system may be abused by some people. I think it's a really nice idea in principle, but I suspect it would be fraught with difficulties in reality. Maybe it's just me being cynical and I would be very pleased to be proved wrong.

RE: Lessons from a GP (Human)

Clare Tapsfield-Wright — Fri, 07 Jul 2017 21:28:11 GMT

I think the lesson we can learn from GPS is that their work has changed from performing consulting, minor surgery, diagnosis and treatment to predominantly triage for everything interesting because every patient except the chronic case is referred. No case continuity and little sense of achievement. This must impact on job satisfaction even if you enjoy consulting. No light relief of seeing a healthy child as all done by health visitors, no house calls, no stitching a cut or vaccinating someone just relentless long hours of consulting. The GPS I know are all jaded , seem to hate their jobs despite the salary and can't wait to retire.

This triaging could be the way our profession seems to want be going too. I recently met a locum vet ten months qualified who is only willing to do consulting and she can easily find work. Is this what we really want to happen or should we keep vets interested fulfilled and committed to staying in the profession?

RE: Lessons from a GP (Human)

Francisco Gomez — Fri, 07 Jul 2017 21:13:56 GMT

I haven't read the thread, just the OP.

One single answer: TIME

RE: Lessons from a GP (Human)

Matthew Plumtree — Fri, 07 Jul 2017 21:10:11 GMT

That's a good point Rob. It's a very sweeping generalised figure. Perhaps one could do a scheme and then offer add-ons for electives, e.g. if the owner REALLY wanted the in-all-probability-a-lipoma mass sent off. It would depend on the values of the staff involved, and one would hope that, as veterinary professionals, we would act ethically. Would be interesting to have a VDS view on it perhaps.

RE: Lessons from a GP (Human)

Rob Davis — Fri, 07 Jul 2017 16:14:53 GMT

I think this is a really interesting idea, but I would worry that you would be opening yourself up to accusations of conflicting interests. It would be in your financial interests to minimise costs, so not recommending histopath, expensive surgery etc. Even though you may make entirely ethical decisions, human nature is such that accusations could be made when things don't go according to plan.

RE: Lessons from a GP (Human)

Julie Innes — Fri, 07 Jul 2017 15:05:49 GMT

I did say TRY! There are many frustrating cases where you need a hint as to where to start. most commonly animals just not eating and/or weight loss with no other symptoms, or PUO. (But even more infuriating when all the blood work comes back normal too!) All I meant was that in some places (eg when I was at Uni), they run bloods on everything as a matter of course.

This is a subject somewhat close to my heart! We have a reputation for being "reasonably priced", and I'm sure other practices think we are "Cheap"- but we're not!!! Our consult charges etc are pretty comparable to other practices, but we keep things simple and don't add-on where it's not necessary. For example: you have an 18 month old Labrador, vomiting and not eating, with a sad face, and you can feel a stone shaped object on palpation of its abdomen. It has a history of eating stones. Finances are limited. You may well want to do an xray to confirm your FB diagnosis, but do you really NEED full bloods etc to open this guy up? Sure, it might throw up something that would be useful to know, but is it necessary? I would always offer, but have rarely done it. IV fluids would depend on the dog's condition at presentation- I don't always give them, of 2 I did last week 1 got fluids, 1 didn't. I can understand that in some cases you might wish you had done bloods etc first, but surely the important thing is to get in quickly and remove the stone.

I also source cheaper versions of the same drug, and look for offers that allow us to keep the cost to the client reasonable. I am NOT trying to be competitive with anyone on price. (Don't know what other people's prices are really, and don't care), but I do want to be affordable, so that animals who need medical attention and who are not insured can get it. I heard someone quoted £1000 for a pyo, which I would find hard to justify, given it's really just a slightly longer op than a bitch spey, and fluids are cheap. If it has pus running out of its vulva and all other relevant clinical signs does it really needs a scan and a blood test before you proceed?

RE: Lessons from a GP (Human)

Anthony Todd — Fri, 07 Jul 2017 14:22:36 GMT

[quote user="Neil Wheadon"]Martin didn't say surprises, he said 'diagnostic clues'[/quote]

OK sorry but "some diagnostic clues you weren't expecting" sounds a bit like a surprise to me.....

Of course there are some, but so far we haven't had even a guess at a hit rate.

I'd still say "bloods" where there are no clinical clues are pretty rare and remember the owner only presents the animal 'cos something is probably wrong.

[quote user="Neil Wheadon"]that fits renal failure so I'll take a blood sample.[/quote]

I'd ask the owner if the cat is drinking more than usual and where and what, er, and then insist on a blood.

RE: Lessons from a GP (Human)

Neil Wheadon — Fri, 07 Jul 2017 11:58:12 GMT

[quote user="Anthony Todd"]

[quote user="Martin Atkinson"]I know you used the word 'try' here but there a numerous occasions when there are very few clinical signs and a bit of fishing is required so a blanket blood profile may well throw up some diagnostic clues you weren't expecting.[/quote]

Not being cynical or critical in any way, but could you put a rough percentage of the number of significant surprises you have had, and where there were absolutely no obvious clues, ie not including the pale MM which turned out to be leucaemia etc.

I reckon the percentage will be pretty low??

[/quote]

Martin didn't say surprises, he said 'diagnostic clues'

Cats are fabulous at hiding disease and are out to trick you all the time. You can look at an aged cat that's thin and think mmmmm.... that fits renal failure so I'll take a blood sample. By doing a wide ranging blood sample at the start in 'selected cases' I will quite often turn up something else and remember that we don't just get ONE disease, a paper a few years ago reckoned that cats over 11 had 7 different clinical diseases.

The other advantage of a wider good sample is cost. The way the majority of practices are set up is that to do a Chem 6 (6 biochemical parameters) isn't a lot cheaper than a Chem 17 / haematology due to all the add ons (blood sample/interpretation fee)

One example this was was a 10 year old indoor cat that wasn't quite right. He had FIV, but I only found that with a wider profile, where the lab did an 'under the weather' profile, but had thrown in FIV as well (I'm not trying to justify test for everything, but the costings make this decision more logical on occasion)

So in answer to your question, more than you think

Neil

RE: Lessons from a GP (Human)

Anthony Todd — Fri, 07 Jul 2017 11:22:28 GMT

I reckon the percentage will be pretty low??

PS I reckon "gold standard", to most clients and practice owners means just "more "gold".

RE: Lessons from a GP (Human)

Thomas Johnson — Fri, 07 Jul 2017 11:19:31 GMT

[quote user="Bob Russell"]The owners of a dog that had a mast cell tumour removed here (with apparently clean margins) went to a particularly well known referral practice at the owners insistence. The scans and chemo have cleaned out the insurance plus bank account and made the previously well patient, unwell.[/quote]

I have just referred a dog to what I think is the same referral centre, a 5 month old GSD from which I removed a 20x10x10cm (yes, it really was that big) mass that had appeared to be inflammatory based on cytology, the results came back as an intermediate grade soft tissue sarcoma. The letter I had back was I though very sensible, they had discussed with the owner that further surgery at this stage would be very extensive, and while it was possible to do it might be better to wait and see what happens, as although the margins were narrow it might not come back, and if it did they could decide how to deal with it at that point.

RE: Lessons from a GP (Human)

Martin Atkinson — Fri, 07 Jul 2017 10:08:19 GMT

[quote user="Julie Innes"] I do make clients aware of all the options, and then discuss them and formulate a plan, based on the animals best interests and the owners finances.[/quote]I always say to clients when they are referred that they should not feel obliged to follow the treatment recommendations and not feel guilty if they feel its not in the best interests of them, their pet or their finances even if the alternative is euthanasia. I do also apply this to my own treatment protocols but as I usually know the client well I'm already in a position to have a pretty good idea of their wishes before we start anyway.

One of my stock comments is: 'when you walk out of here you need to know that you are happy with the decision you made and not wish you done something different but for whatever reason I won't think anything worse of you if it is not what I recommended', (unless they're being total a**holes!

[quote user="Julie Innes"]I try to only do tests to confirm a suspected diagnosis, rather than as a fishing exercise,[/quote]I know you used the word 'try' here but there a numerous occasions when there are very few clinical signs and a bit of fishing is required so a blanket blood profile may well throw up some diagnostic clues you weren't expecting.

RE: Lessons from a GP (Human)

George Cooper — Fri, 07 Jul 2017 09:17:40 GMT

One of the most encouraging comments I had was from the Medical Officer at the Hospice where my wife spent her final month, and that was, quite categorically "We treat human beings, not blood results." Closely followed by "If, in the course of a treatment, side effects develop, then we treat those if and when they occur. The possibility of a side effect does not mean we withhold the treatment."

Of course the Hospice situation and the palliative care concept can be viewed as a rarified atmosphere in which treatment decisions are made to different requirements, though it is my take on our treatment of our patients that we could do well to follow the broad example of the Hospice.

One example stands out - and this in an establishment where more than half of the nursing staff had been clients of mine (!). For some reason one night her anxiety levels rose fairly alarmingly and some time way after proper "bedtime" I commented to the nurse that if she had been a patient of mine I would have had her sedated/anaesthetised pretty sharpish! The nurse's reply was "THAT, George, is actually on its way as we speak" and sure enough the midazolam was administered to effect within minutes.

RE: Lessons from a GP (Human)

Julie Innes — Fri, 07 Jul 2017 09:06:27 GMT

I've always been a hater of the "Gold Standard" misnomer. Like others, I have seen some questionable things at referral centres- eg a 16 yo FIV +ve cat having brain surgery for a tumour (I euthanized him a few weeks later). I do make clients aware of all the options, and then discuss them and formulate a plan, based on the animals best interests and the owners finances.

Re bloods etc: I try to only do tests to confirm a suspected diagnosis, rather than as a fishing exercise, and look at the results in conjunction with clinical signs (so I don't hopefully head down a wrong path)

My first job was very basic, and I remember my old boss telling me that "response to treatment is a valid diagnostic tool!"

RE: Lessons from a GP (Human)

Bob Russell — Thu, 06 Jul 2017 16:04:10 GMT

The main reason my definition of gold standard is the level of care In would want for my pets. Enough to make a reasonable choice of treatment but no more than is required to do this.

The owners of a dog that had a mast cell tumour removed here (with apparently clean margins) went to a particularly well known referral practice at the owners insistence. The scans and chemo have cleaned out the insurance plus bank account and made the previously well patient, unwell.

I tried to (diplomatically) warn them in advance that this would be the case and suggested a much more pet friendly referral clinician.

Several months on the owners are accepting I was right! Happened in both the cases that were referred there.

Gold standard does not mean every scan and the most aggressive chemotherapy. On occasions it may but not always.

RE: Lessons from a GP (Human)

Evelyn Barbour-Hill — Thu, 06 Jul 2017 14:21:41 GMT

[quote user="Arlo Guthrie"]

[quote user="Neil Wheadon"]and 'gold standard - I hate that term' [/quote]

You and me both, actually. In fact, it's a bit of a misnomer, I think, because it implies 'all the tests/treatment', when in reality, surely true 'gold standard' is getting the patient well with the least amount of (possibly painful, and certainly inconvenient) tests/treatment.

[/quote]

Nutshell.

RE: Lessons from a GP (Human)

Arlo Guthrie — Thu, 06 Jul 2017 13:23:26 GMT

[quote user="Neil Wheadon"]and 'gold standard - I hate that term' [/quote]

RE: Lessons from a GP (Human)

Matthew Plumtree — Thu, 06 Jul 2017 12:52:28 GMT

Likewise, we offer clients "the range" of options. My point is that there is nothing wrong with innovating and trying new ways of doing things from a service delivery point of view to benefit more patients. I totally agree RE vet students and the "gold standard". We've become a popular destination for students in recent years and we try and give them as much real-world exposure as possible.

RE: Lessons from a GP (Human)

George Cooper — Thu, 06 Jul 2017 12:37:41 GMT

Two points here - and forgive the turbo lag posting.

Fairly recently I agreed to help out in a practice by doing a goodly number of Saturdays for them (in order to keep me in fast cars and better guitars) and all was 'well' until on two occasions I thought that I might become an embarrassment to them. Both cases involved hyperthyroid elderly cats. Both had palpable thyroid glands and all the recognised signs associated with the condition. My approach has been, for 25 years, to dive in and operate without necessarily pulling any tests, having had long-ish discussions with the owners. This approach was "taught" me by a younger, more gifted colleague who had seen many more than I had at that time, and it has stood me in good stead ever since having now probably operated on well into three figures in that time. There have been possibly a handful (if that) which either developed a palpable mass on the other side of the neck, or which succumbed in the days following surgery (the risk of which is always explained to the owner, and where the cat was really elderly.) The first case that incurred the displeasure of the Gold Standard adherents belonged to a very elderly farming widow who readily accepted the risks (and hers was a poorly puss) and who was very careful with her dosh. Surgery in my hands will incur costs of less than £200 as the op takes very little time indeed.

The second case was much more interesting........ I had discussed the ins and outs with the lady owner and told her the options of surgery, daily pilling, or radio-activity following extensive tests as the gold standard would decree. I also explained why, in my opinion, i felt that the surgical procedure done asap would serve her puss admirably. at that pint she pulled out her mobile and said that it would be a good thing if i could explain it all again to her husband as he would be very interested and she would be unable to explain it as well as I could. (kind of her, i thought). I then had a conversation - mainly one-sided with a lot of silences at the other end - with her husband, who, at the conclusion of the "discussion" said "I agree absolutely with your approach, and I commend it. Proceed." Flummoxed? Me? Yeah - just a bit..... He then explained that he was an NHS consultant and surgeon who's speciality was in thyroid!!

I still had my knuckles rapped (nicely) for not following practice policy of gold standard, so i resigned as I could see the possibility of clashes in the future, what with me being an opponent of the "because we can, I am going to do it" brigade.

Clients want their pet well again, and not a "name" for what is wrong.

My second point concerns the B2B part of veterinary practice - that of serving the farming industry. We developed a scheme that roughly fell under the title of "Unconditional Veterinary Service" whereby, in exchange for a monthly fee we would do whatever it took to provide the care for that farm, including, and this was important, a meaningful Health Plan delivered not as a tick-box affair but a well constructed and monitored system. It meant for example that if there was a downer cow that needed repeat visits, there would be no constraint(or additional fee) for those repeat visits. This was considered possible because vet practice is a fixed cost enterprise, and the only additional cost to me would be a drop of petrol for repeat visits.

Their fee was calculated on their previous spend with the practice (plus a bit more to cover the changes), and they were provided with drugs at cost. This was because imported meds from Ireland were a bit of a problem at the time. Any discount we made through astute purchasing was ours and not passed on.

We had an astonishing number sign up - and contrary to what you cynical so and sos might think, NONE of them took the mick and exploited the stystem. They were really in favour of the idea and saw it as a way forward. (I had 2 previous motivating influences - Paragon Vets' David Black dod something similar, and the H&S and HR specialists endorsed by SPVS whose name escapes me offered unconditional support to practices).

Unfortunately just as the scheme was getting underway with more farms joining, life was subject to seismic changes for yours truly and it meant I had to abandon life in Herefordshire and emigrate to the wilds of Wales!

RE: Lessons from a GP (Human)

Neil Wheadon — Thu, 06 Jul 2017 12:11:19 GMT

[quote user="Matthew Plumtree"]Most of my clients have an annual household income in the £10-19k bracket, so this is a situation I commonly find myself in with their pets. From their point of view their animal is suddenly ill and they may not have the £70-80 for a blood test, never mind the hospitalisation or surgery fee.[/quote] I locummed a few years ago .... somewhere. The area was incredibly poor. Consults were £15 and it was mostly 'non testing' consults. I diagnosed much by clinical exam and history. The vet was popular, busy and the vast majority of clients were content with what was available. He had tailored to his audience. He had a lovely house next door and was on holiday abroad. So yes it can be done, maybe this sort of experience should be compulsory to University lecturers and maybe vet students should be required to see practice in these places rather than referral type places to install a sense of reality and to show that yes you can practice happily, effectively and 'gold standard - I hate that term' is not the be all and end all Neil

RE: Lessons from a GP (Human)

George Cooper — Thu, 06 Jul 2017 12:02:49 GMT

[quote user="Bob Russell"]

Sadly people have to be realistic! If they have limited incomes and do not take out insurance we are going to be limited in our diagnostic accuracy.

When I qualified the number of blood tests done was far, far lower. We managed to treat most patients pretty effectively with diagnostics limited to a good history and clinical examination.

If a client makes it clear some things are not affordable then I accept it and do the best I can. Many patients do well!

An example would be the coughing elderly dog. Trial on frusemide, is much happier and continues without diagnostic costs. The owner has to be aware of the limitations but I find most are accepting and grateful that we have not given up.

[/quote]

Bob - congratulations on a most sensible, rooted-in-reality-post, with the exception of your first sentence, with which I take issue. People ARE realistic, and are guided purely by what YOU say in the consultation. You have the power to accept the responsibility for their pet's healthcare and to set out a sensible, affordable plan to restore their animal to health (hopefully). Clients do NOT want to know the very name of every condition - their simple wish is to have a well pet again. If itchy - to have a calm dog. If puking, to be able to keep it all down. If coughing - to be spared from that cough. etc etc etc

RE: Lessons from a GP (Human)

Bob Russell — Thu, 06 Jul 2017 11:31:41 GMT

Sadly people have to be realistic! If they have limited incomes and do not take out insurance we are going to be limited in our diagnostic accuracy.

When I qualified the number of blood tests done was far, far lower. We managed to treat most patients pretty effectively with diagnostics limited to a good history and clinical examination.

If a client makes it clear some things are not affordable then I accept it and do the best I can. Many patients do well!

RE: Lessons from a GP (Human)

Matthew Plumtree — Thu, 06 Jul 2017 11:22:54 GMT

As do we all I hope! The problem comes when (as with any walk of life) you may suddenly have a large unanticipated bill to pay, and the ability to pay becomes the main obstacle to the best outcome for all parties. Most of my clients have an annual household income in the £10-19k bracket, so this is a situation I commonly find myself in with their pets. From their point of view their animal is suddenly ill and they may not have the £70-80 for a blood test, never mind the hospitalisation or surgery fee. Many animals are euthanised when, if barriers were removed such as with the the NHS free-at-point-of-care model, they might not be. It's about finding another way to deliver our service and care to more patients in need of it whilst still being paid to do it and balance the books.

RE: Lessons from a GP (Human)

Bob Russell — Thu, 06 Jul 2017 11:02:28 GMT

I discuss all reasonable options, giving an idea of cost.

I also make it clear that in many situations what can be done does not equate with what should be done.

Age should be respected and treatment choices should be made in a sympathetic way that puts welfare of pet and client at the top and clever stuff for the sake of it, much lower.

Gold standard for me is how I would choose to treat my pets!

Are we really here to clean out bank accounts or to be good vets?