Mixed practice.

RE: Mixed practice.

Thomas Johnson — Tue, 25 Jul 2017 19:07:26 GMT

My first job when I qualified 14 years ago was in mixed practice on the Worcestershire/Shropshire border, there was a fairly even mix of farm and small animal work, and some equine work as well. The farm animal side was mostly dealing with individual animals, we didn't do much herd health work. I was well supported and encouraged to do a wide range of work on all sides of the business, and we always had a 1st and 2nd on call vet so there was always someone to call if there was a problem. I think having to deal with a wide variety of problems across different species has been very useful for me. I discovered recently that the practice no longer does any large animal work, they sold that side of the business to a neighbouring practice and have continued as a small animal only practice.

My second job was in a mainly small animal practice where the senior partner did some equine work, which meant that all the vets were expected to see horses out of hours. Most of us had worked in mixed practice before working there and were comfortable treating horses, but a new grad who started at the same time as me really struggled, to have to deal with an equine emergency once every couple of months when you otherwise never treat a horse is very challenging.

My third job was another mixed practice, this time in Sussex, I left there 6 years ago but recently bumped into one of the partners at a CPD event. They are gradually losing their larger farm clients to practices such as Westpoint and a lot of their farm animal work is smallholdings and hobby farmers and I wonder how profitable it is going to be to continue to do this work.

I am now in small animal only practice and have been in my current job for six years. I do miss the farm animal work, I liked working with farm animals and farmers, and I enjoyed getting out of the practice. However I realised that I was progressing with my small animal work, getting better at it and doing more, but wasn't doing anything new on the farm animal side. I could see that there was a lot more I could be doing on the farm animal side with herd health planning, preventative medicine etc. but I couldn't see how I could devote the time needed to learn and practice the skills while continuing my progress on the small animal side. I also had moved to take the job and was feeling a bit isolated. These factors combined and I made the decision to go into small animal only work. It is much more intense than large animal work, but I do enjoy what I do and feel that I have continued to develop my small animal skills quicker than if I had stayed in mixed practice.

RE: Mixed practice.

Martin Atkinson — Mon, 24 Jul 2017 12:29:09 GMT

[quote user="Michael Woodhouse"]I suspect Martin Atkinson farm experience was probably very different to how farm practice is today. I suspect small animal practice was very different back then too.[/quote]You're only partly correct on both counts. But I suspect farm work has changed little in relation to the vast advances in small animal work. Whatever, I can only compare the difference I felt back then as an assistant: as said I found LA work generally boring, repetitive, lacking in intellectual challenge and a waste of my surgical skills - the opposite of SA work.

As for stress, and again I can only speak of then not now but just for one example: I found the decision making and surgery performing a cow caesarian in sub-optimal conditions far more stressful than a canine one.

Maybe I have come to terms with my ability and limitations, self-confidence and sang froid but I don't find small animal practice any more stressful than life in general. That is apart from the running of the practice which can be at times but that is the same across the board.

RE: Mixed practice.

Michael Woodhouse — Mon, 24 Jul 2017 10:57:44 GMT

I would be interesting to compare stress levels in different types of practitioner.

I suspect Martin Atkinson farm experience was probably very different to how farm practice is today. I suspect small animal practice was very different back then too.....

RE: Mixed practice.

Martin Atkinson — Mon, 24 Jul 2017 10:39:49 GMT

[quote user="Kate Richardson"]errr they do have dogs and cats in the countryside......[/quote]But probably not in large enough numbers in a small village to support a 100% SA practice.

[quote user="Stephen Courtney"]

All the responsibility of a private paediatrician/psychiatrist rolled into one, with a depressingly low glass ceiling.[/quote] The ceiling as high as you want to set it, I haven't reached mine yet but I felt I had after just a few months in LA practice.

RE: Mixed practice.

Robin Grimmer — Sun, 23 Jul 2017 20:08:38 GMT

[quote user="Stephen Courtney"]

All the responsibility of a private paediatrician/psychiatrist rolled into one, with a depressingly low glass ceiling.

[/quote]

I think you've summed up the pressure of small animal practice in a nutshell there.

RE: Mixed practice.

Julian Earl — Sun, 23 Jul 2017 20:05:47 GMT

[quote user="Iain Richards"]However, while I know what you mean, I'd put the intellectual challenge of creating a parasite control plan, or a nutrition plan, or altering a lambing date on a par with sorting out an Addisonian case. Surgery, yes, limited opportunities, unless you look for them....[/quote]

I agree with you Iain, in that the intellectual challenges are different, but the key aspect of mixed practice for me was the sheer variety of challenges. You might be aware Iain, but the most enjoyable part for me had been herd and flock-based problems that really gave me something to get my teeth into.Individual cases can be stimulating and satisfying but looking at the bigger scheme of things was always more rewarding mentally. I honestly believe that this must be the future for LApractice. If new graduates do leave LA-work quickly, I think that they have not had the chance to experience the variety of work one sees over time I mixed practice. Purely SA work gives more opportunity for detailed investigations - sometimes. ?But a detailed mastitis investigation is just as intellectually stimulating and worthwhile. Even in mixed practice I've seen plenty of unusual species over the years so mixed work does not exclude developing an interest in reptiles or ferrets etc., etc.

RE: Mixed practice.

Stephen Courtney — Sun, 23 Jul 2017 19:46:01 GMT

I actually feel that mixed practice vets are the only 'proper' vets out there, in a Herriotish sort of way. I have massive respect for anyone who can calve a cow, deal with horse owners, trim feet, cleanse cows, cope with the physical side of things that i have never ever done...

but I also think it depends on where you are, and what your client expectations are. i truly doubt a true generalist would cope well in some of the intensive small animal environments...to be honest Im starting to feel I don't either. All the responsibility of a private paediatrician/psychiatrist rolled into one, with a depressingly low glass ceiling. What joy. Maybe life would be far better working for farmers!

RE: Mixed practice.

Emily Rainbow — Sat, 22 Jul 2017 20:22:53 GMT

Ive recently given up mixed practice due to a need to move across the country and have gone locuming which is predominantly smallies work as not many mixed practices in the area.

Really miss the variety and the fact it's always busy! I don't do being bored very well!

RE: Mixed practice.

Busybee — Sat, 22 Jul 2017 19:56:03 GMT

I'm a seven year qualified female vet working in truly mixed practice (well, smallies and farm with the odd horse) in the Cotswolds - a rarity??

The majority of my uni friends have 'specialised' by now, most going to small animal practice. When we meet, I nearly always get surprised reactions that I'm still in mixed practice.

I love the idea of consulting in the morning, going out to do a bit of fertility work, vaccinating a horse then returning to do a stitch up or bitch caesarean. If I get stressed about one aspect of the job, I just go and do another aspect. I rarely get bored. I feel my small animal work improves my farm animal work and vice versa. I have made a lot of acquaintances with both the farmers and the small animal clients, and often find the farmers easier to get on with and have a laugh. A cup of tea after a visit never goes amiss either!

Yes, we have to do our own OOH but this is where you get a lot of the interesting cases and learn to work independently rather than relying on others. That's not to say I always enjoy it or look forward to my weekend working!

I am lucky in that we have good working hours, plenty of support from the other vets and work in such a beautiful place. If anyone knows of any students that want to try mixed practice, get in contact! They'd love it! If they don't get exposed to mixed practice during EMS, the university teaching environment tends to encourage specialisms.

RE: Mixed practice.

Kate Richardson — Sat, 22 Jul 2017 07:38:22 GMT

[quote user="Martin Atkinson"]

[quote user="Neil Wheadon"] Certainly not boring if you like that, and the fresh air and farmers....mmmm....maybe I ought to go back...[/quote]The one regret I have about choosing small animal practice is that I have missed the opportunity of being one of the few people who have a vocational reason to live in the countryside. Farmers, like horse owners, I don't miss!

[/quote]

errr they do have dogs and cats in the countryside......

RE: Mixed practice.

Chris Milligan — Fri, 21 Jul 2017 18:20:08 GMT

Depends where you are geographically more than anything. Live in a big city? Clearly mixed practice is not going to be something you engage in. With all the choice and dedicated small animal clinics why would you go and see someone who spends less than 100% of their time dealing with your kind of animal (no offense to dedicated mixed practitioners!) - but if you live rurally then I would say mixed practice is an essential service. There's a lot to be gained from knowing your other species - I work solely in small animal emergency but the fact that I do means you often have to think laterally a lot and that lateral thinking tends to be better nurtured in farm animal medicine. Whilst I'm confident I would be struck off in a week if I ever tried to treat a farm animal I'm grateful for the wider skills it provided. The main problem with mixed as ever is that there's so much to know these days about everything that you simply can't be great at it all. Not to say you can't be good at it all though!

RE: Mixed practice.

Wren — Fri, 21 Jul 2017 13:47:00 GMT

[quote user="Neil Wheadon"] and the fresh air and farmers....mmmm....maybe I ought to go back...[/quote]

I must have liked them. I married one!

RE: Mixed practice.

Anthony Dennison — Fri, 21 Jul 2017 12:13:20 GMT

[quote user="Michael Woodhouse"]I simply don't see that. Dealing with complex disease at herd level is way more complicated than simple disease in a single pet. A boring conversation about diabetes, fleas, or hypo T4 goes the same every time. Deal with mastitis and it's something different every time with different risk factors etc. I will often have very complex conversations with farmers about disease testing in different populations, Martin Atkinson - when did you last talk about the positive predictive value of a test? We do DA's laprascopically, quite a bit of small ruminant surgery. I always found finances more limiting in small animal rather than large animal practice. [/quote]

I'm with Michael on this one. I chose small animal work over farm work because I always found herd health took me longer to get my head around and sort, whilst smallies work came naturally to me.

It's also harder with the limited number of drugs that can be used when talking about withdrawal periods, farm to fork traceability is increasing year by year and more consumers are wanting to know these things so farm vets are having to work closer than ever with farmers to do this.

Yes as a small animal vet I can see individual animals with complicated diseases, often lots of co-morbidities, but it's an individual animal. Often sick farm animals aren't individual problems, it's more of an indicator of a farm-wide problem that may even be interspecies or zoonotic.

Give me an atypical Addisonian dog with diabetes and heart disease any day.

RE: Mixed practice.

Martin Atkinson — Fri, 21 Jul 2017 12:09:14 GMT

RE: Mixed practice.

Neil Wheadon — Fri, 21 Jul 2017 11:40:33 GMT

Stress is related to feeling you are doing the job properly

Like Martin (though, I know longer than him because I read his book) I was in mixed practice for 10 years and the breadth of knowledge to do a good job in both is beyond everyone.

Large animal practice is a different beast to 20 years ago, far more complicated but more epidemeolgy than fire fighting. Certainly not boring if you like that, and the fresh air and farmers....mmmm....maybe I ought to go back...

Cherry picking though is easier. Go out and do a herd health scheme and come back and do a spot of orthopaedics (Large animal vets love orthopaedics, it's the physicality of it) However add in cardiology, dermatology, need I go on and it's impossible isn't it?

Neil

RE: Mixed practice.

Martin Atkinson — Fri, 21 Jul 2017 09:55:53 GMT

[quote user="Michael Woodhouse"]I simply don't see that. Dealing with complex disease at herd level is way more complicated than simple disease in a single pet. A boring conversation about diabetes, fleas, or hypo T4 goes the same every time.[/quote]Perhaps you'd like to deal with just one of my diabetic feline patients I saw yesterday with an unstable glucose curve. It is also hypothyroid following I131 therapy for hyperthyroidism, has CRF which is made worse by the hypothyroidism, is acromegalic and has autoimmune skin disease which requires medication the owner can't give orally and she's not too bright about giving the insulin injections either!

All I can relate to is when I was in mixed practice I found large animal work, dull, repetitive and unrewarding. The intellectual challenge of managing a case like the one above was far greater than any herd management problems. If your diabetic and hypothyroid cases are boring and go the same way every time I would suggest that you are either incredibly lucky they are stable or you are not monitoring then closely enough.

RE: Mixed practice.

Michael Woodhouse — Thu, 20 Jul 2017 21:23:05 GMT

[quote user="Martin Atkinson"]

In the end I chose small animal practice because of the greater intellectual challenge*, the ability to use my diagnostic and surgical skills on a daily basis and the financial reward for my skills - not so much for making money more because I wasn't limited to such an extent in what I could do by economics.

*While I don't denigrate large animal colleagues and I'm sure they are just as bright (or not) as me but there is no doubt that SA practice uses a much larger proportion of our skillsets, requires a much wider in-depth knowledge and much greater amount of time keeping up to date if we're going to do the job properly all of which I find more rewarding.

[/quote]

Pardon?!

I simply don't see that. Dealing with complex disease at herd level is way more complicated than simple disease in a single pet. A boring conversation about diabetes, fleas, or hypo T4 goes the same every time. Deal with mastitis and it's something different every time with different risk factors etc. I will often have very complex conversations with farmers about disease testing in different populations, Martin Atkinson - when did you last talk about the positive predictive value of a test? We do DA's laprascopically, quite a bit of small ruminant surgery. I always found finances more limiting in small animal rather than large animal practice.

I can fix pets, but its boring and repetitive. I'm sure the farm work is more complex and there is a level of satisfaction that can only be gained from physically working at a calving/caeser/prolapse that doesn't exist in small animal practice.

RE: Mixed practice.

Martin Atkinson — Thu, 20 Jul 2017 17:21:15 GMT

[quote user="Iain Richards"]It's worth doing them at whata might be considered unprofitable rates, but then SA practices rarely charge the right rate for spay, so it's a farm equivalent.[/quote]The difference is that practices which charge silly prices for spays are using them as loss leaders ready to sting the client later when they are a captive audience. Farmers are too astute (and fiscally constrained) to fall for that unless you consider dry cow management as the sting.

RE: Mixed practice.

Rob Loxley — Thu, 20 Jul 2017 17:20:03 GMT

[quote user="Wren"] I have to say that doing SA on call, while not doing any working hours stuff was pretty challenging[/quote]

Likewise many 'mixed' practices where one of the partners does all the day work yet wants the [essentially therefore small-animal] assistants to do the OOH or just cover their holidays?

RE: Mixed practice.

Iain Richards — Thu, 20 Jul 2017 14:52:54 GMT

True, Martin. However, in the dark days post BSE when cattle were worth very little, we ran a no-win, no-fee option. It increased our surgical case load and we got very good at laparotomies. So when prices picked up we approached with more confidence. (One farmer betted me on the outcome, double or quits if it survived a week. She died, neeedless to say, with half a day to go). Farmers like seeing them done, especially if you are slick with LDA ops. It's worth doing them at whata might be considered unprofitable rates, but then SA practices rarely charge the right rate for spay, so it's a farm equivalent. The real profit would be turning the 3rd LDA in a row into a discussion on dry cow management!

RE: Mixed practice.

Martin Atkinson — Thu, 20 Jul 2017 12:08:29 GMT

[quote user="Iain Richards"] Surgery, yes, limited opportunities, unless you look for them....[/quote]You can look for them but who pays for them - at least at a profitable rate?

RE: Mixed practice.

Iain Richards — Thu, 20 Jul 2017 11:52:33 GMT

Martin Atkinson - thems fightin' words...

However, while I know what you mean, I'd put the intellectual challenge of creating a parasite control plan, or a nutrition plan, or altering a lambing date on a par with sorting out an Addisonian case. Surgery, yes, limited opportunities, unless you look for them....

RE: Mixed practice.

Martin Atkinson — Thu, 20 Jul 2017 11:16:43 GMT

Like most vets of my generation I saw practice in mixed practice and my first jobs were in mixed practices. I enjoyed all the work but the biggest problem was the attitude switch from the large animal work which was mostly preventative, limited opportunity to use my surgical skills and the economic reality. I found it very difficult to switch mindset from a day out on the farm where everything was governed by economics to an evening surgery with clients who had much higher expectations and were prepared to pay for them, especially if I'd not had chance to change and was still sweaty and stinking of cow sh1t!

RE: Mixed practice.

Wren — Thu, 20 Jul 2017 09:00:14 GMT

It's an interesting question, and one I can see from both perspectives. I did 14yrs in a very mixed rural practice - everything from brucellosis/TB testing to horse lameness to GDVs to penguins. Initially I did a real mix of work, but latterly I dropped most of the SA work, apart from the OOH. I have to say that doing SA on call, while not doing any working hours stuff was pretty challenging, and in the end I just felt that I wasn't doing my clients a good enough service in that respect.

I now work in 100% equine and I can honestly say that I wouldn't be the horse vet I am without having done the mixed work. My suturing skills are better than most, thanks to the hours doing SA ops (you don't do enough stitch-ups on horses really to develop decent proficiency). I am much better at foalings as a result of the several hundred cattle I have calved - I have an appreciation of what is and isn't going to come and what to manipulate where and when that I just couldn't have learned from doing 1, maybe 2 foalings a year. And I have an attitude of coming up with solutions or trying things out which also comes from the farm work where often you have to be pretty inventive. Interestingly I hated herd health work, and it's one of the reasons I left LA practice, yet I have started doing herd healt and biosecurity plans for our riding schools and livery yards based on my general knowledge and skills in that field learned over the years on farms.

I really am against early specialisation and think that the long-established route through mixed practice is hugely valuable. It's also character building - and you do learn to fend for yourself very quickly - when out doing farm or horse work there is no-one in the next consulting room that you can ask to pop in to have a quick look at something for you, or get the vein you're struggling with. They're probably 20 miles away!

I suspect new grads don't want to do it for the reasons above. The OOH is HARD work (although I'd argue that that too is a very good education, especially done while you're young enough to cope with the missed sleep) and it really does wear thin after a while. I now work a much more frequent rota than I did when I was in mixed practice (1 in 2, cf. 1 in 4), but honestly, the relief of knowing that you're not going to have to do 2 cow caesars in the same night, or have to spend an hour at midnight reading up on the notes of a dog with decompensated heart disease and try to come up with a coherent plan is worth it. Generally, and I am probably jinxing it now, horse owners don't see their horses between early evening and the next morning, so the number of disturbed nights is much, much smaller.

The other issue is the one of non-progression, which I can definitely identify with. You are quite possibly going to end up doing all the rubbish, hard, monotonous, non-rewarding jobs. When I left I was doing 100% of the TB testing and export work for a 4 man practice, which was soul destroying. However there are jobs and employers that will let you carve your own niche. I am free here to specialise clinically as I see fit. I do a lot of marketing work and have set up clinics with visiting specialists. I have an interest in dentistry and am trying to develop that side of the practice. Many bosses will be thrilled to have someone with motivation and enthusiasm and be open to letting you forge your own path, to a certain extent. And I think if you're stuck in a dead end job (and these aren't confined to mixed practice!) where the boss does orthopaedics and only goes to the 'nice' farms, while you are stuck with 4 hours of SA nail trims and anal glands and when you do get to go in farm visits it's foot trimming at Mr Featherstone's, whose crush was bought in 1934, whose cattle are wild and whose yard in knee deep in mud/slurry, then it's probably time to investigate other options!

RE: Mixed practice.

Michael Woodhouse — Wed, 19 Jul 2017 23:36:05 GMT

I do think there is a future for mixed practice and I think it takes a bit of flack that is very undeserved. Many of those who've gone into single species practice seem to think that someone who treats multiple species is somehow inferior - using phrases like "farm only" or "dedicated equine vets". This completely fails to allow for the bredth of experience gained by treating multiple species of animals and the cross over in experiences. I'm a better farm vet because I do some small animal and equine work, not worse. It means I have skills and equipment that I'd never have as a dedicated farm practice.

We go to great lengths to practice to as high a standard as we can and are well equipped in all areas. We have our own special interests (most of my work is cattle) but still all do a bit of everything - I have a cruciate op to do in the morning after some cows. I like the variety.

We go to great lengths to develop younger staff, in all areas of practice. I personally do more fertility work and little TB testing, but I took one assistant out scanning today and taking another out with me on Friday. I want them to be able to step in and scan when I am away and I want them to take on some routine work themselves. I will ask if one of them wants to scrub in to the cruciate op tomorrow.

Our last assistant went the other way and went to 100% farm.

I do like the fact I've done caesareans on 3 different species in the same week. I've done some orthopaedic surgery in sheep. We often GA calves and put them on gas for hernias etc.