Madness from referral practices

RE: Madness from referral practices

Edward Jones — Mon, 05 Mar 2018 12:27:43 GMT

Windows 10 has a useful window tiling function - drag the title bar to the left or right edge and it'll resize the window to take half the screen, then offer icons to let you select which other window you want filling the rest of the screen.

The biggest problem with web forms is recovering after a malfunction or user error. My email program automatically saves a draft every few seconds, whereas a minor malfunction or misclick can lose a whole web form.

RE: Madness from referral practices

Bob Russell — Mon, 05 Mar 2018 10:07:45 GMT

We have several local referral centres. I value each and every one of them!

We tend to send the relevant history directly from our PMS. I send radiographs as Jpegs or Dicom files and/or burn them onto a disk for the client to take with them.

There is little doubt that costs are going to be much higher at referral centres. I will send patients we could probably have dealt with here if I feel we cannot care adequately afterwards.

One of the main reasons for a lack of specialists is that every corporate group wants to have its own centre to send its own patients to.

CVS, IVC and Pets at Home group each have their own referral centres within 30 miles of us. Just as every corporate seems to feel the need to open up or take over a practice within a few hundred yards of each other.

I don't believe this is really sustainable but then I have been saying this for a decade and they still keep opening up! Plans for more in the pipeline apparently.

One area not far from here there are ten or more (depending on where you pick a spot) practices within a ten minute drive. No surprise that these are busy cutting each others throats with loss leaders. pet clubs etc.

Hardly sustainable and higher interest rates are likely to make life interesting!

RE: Madness from referral practices

Thomas Johnson — Mon, 05 Mar 2018 09:48:53 GMT

[quote user="J G Wray"]

[quote user="Andy Moores"]The submission form. We have an on-line submission form too, but it's not compulsory. We will accept referrals however you want to make them -phone/fax/on-line/email. Our feedback is that lots of vets like the on-line process since they can do it straight from their computer in the consulting room. Our form has 25 fields. Not all are compulsory. I just tried it out and it took me less than 2 minutes to fill in.[/quote]

Try this when moving between screens from a PMS

[/quote]

Depends on the PMS, with ours all of the patient and owner information is displayed at the very bottom of the screen, so with the web browser a little smaller than full screen I can still read all of the information from the PMS while filling in the form.

Though I would say that some online forms are much better than others, I'm happy to use forms that want my details, as well as those of the client and patient, give a brief summary of the problem, and then allow me to either upload or email the rest of the documents, referral letter, clinical history, lab results, radiographs, etc. What I don't like are forms that have lots of boxes for me to write out clinical summaries, medication lists, lab results, etc. With these there is no avoiding going backwards and forwards to the PMS and it takes significantly longer than writing a comprehensive referral letter.

RE: Madness from referral practices

Wren — Mon, 05 Mar 2018 09:01:30 GMT

[quote user="Andy Moores"]I wonder if anyone would prefer the US situation where clients can self-refer without having to go through their 1st opinion vet?[/quote]

This is already a common scenario in equine practice. A lot of clients make their own decisions about whether their horse's problem is likely to be something that can be diagnosed/treated by the first opinion ambulatory vet at their yard, or whether it is likely to require hospital work-up and/or surgery. If the latter they will often transport the horse to a hospital themselves without notifying their first opinion vet. If the referral practice realises that this is the case, then they will generally contact us to let us know, but the client will often present to them as either a 'new client', or they they have done this before, so are already registered on the referral practice's system. The first I get to know about it is a request to remove the stitches, or if I go to a colic and they just happen to mention the extensive medical investigations that the horse had 2 months ago...

It is quite infuriating, but I can also see it from the client's point of view. I am relatively sure that money in the main motivator - they know that if they get us out to do a preliminary exam/work-up on a horse which will inevitably be referred then they will have to pay us £100+ pre-referral, when they could cut that out by going directly to the hospital. I am trying to educate our clients that at the very least if they give us a ring first then we can arrange the referral through 'proper channels' which means that we will at least receive reports back and everyone stays on the same page. The more communication, the better for the animal (not to mention the vet), surely? I doubt we will stop people doing this, but I want them to be more open about it, rather than feel like they are sneaking off behind our backs. We do differ from SA practices in that we can't offer any surgery (other than castrates, small lump removals etc.) here, so it's not as though the client is choosing them over us for something that we can both offer.

The other reason I suspect that some do it is so that the record of the suspensory op etc. is with a third party and we never get to know about it. When the client comes to sell the horse and tells us we can disclose the history to the potential purchaser, all there is to be seen is vaccinations, routine dentistry and the odd cough - no record of the long and complicated lameness...

RE: Madness from referral practices

Evelyn Barbour-Hill — Sun, 04 Mar 2018 17:20:35 GMT

[quote user="Andy Moores"]Wow! What a thread. I feel compelled to wade in and add to Rob and Andrew's voices to defend our side of the profession...[/quote]

OK, I'm writing from both sides at once, being both an occasional maker and a frequent acceptor of referral. I detest the division of the veterinary profession into Specialists and General Practitioners.

[quote user="Andy Moores"]On the subject of the referral process, what we really love is a concise summary of the reason for referral in a referral 'letter'. This does not have to be a formal letter, it can be a paragraph or two within the clinical notes, but a summary of the condition, the reasons for referral and directed towards the referral centre.[/quote]

That's nice, but plenty of "referral centres" insist on the form. You will never get past the receptionist otherwise.

For myself, I'm happy with a few quick words over the telephone outlining the problem and anything else I really need to know. If the referrer has taken some radiographs, that's good, but I'll probably take some more at odd angles to satisfy myself.

But when I've sent a "referral centre" comprehensive notes together with my own thoughts, I'm not sure they actually got read.... as when I referred a baffling longstanding case that was either neurological or neuromuscular, they did not investigate the problem but seized on the coincidental pruritus that had recently appeared and sent it to the dermatology department, who diagnosed (correctly) Trombicula autumnalis infestation and prescribed (unnecessarily complex) treatment, and sent me a patronising report all about harvest mites (signed by an intern).

[quote user="Andy Moores"]generally if a case is referred we will deal with it from diagnosis through to definitive treatment, which is what most owners want (and also most referring vets I believe).[/quote]

Sometimes, sometimes not. If I refer a patient with an oral cancer specifically for assessment for radiation therapy, I get pretty cross if the referral surgeon talks the owner into letting them do surgical removal instead. A piece of surgery that I had already offered to the client and which I could have done (this being within my speciality) just as competently as a university surgeon, with just as good chances of a cure, with possibly better cosmetic results and certainly for a smaller fee. Some referral centres clearly feel that they are so superior at everything that they are taking the patient over. Of course it's the owner's choice, but once the centre have the patient there it's not too hard for them to steer the owner ......

[quote user="Andy Moores"]the UK has a shortage of specialists. Specialists are commanding ever-higher salaries[/quote]

Commanding? I refer you yet again to the opening number of Gold Diggers of 1933. Or if you prefer, to Barrett Strong c. 1960, or to Fleetwood Mac c. 1970.

[quote user="Andy Moores"]At the end of the day the relationship between the primary-care practice and the referral practice should be mutually beneficial and respectful (in both directions).[/quote]

Absolutely. So why is it sometimes not, I wonder?

And finally..... no 'tain't, it's "draw". A debate almost as hot as that on the question as to how many angels can dance on the head of a pin (the answer is of course 34, in my opinion) but not as unpleasant as that on the question as to whether someone who is not RCVS Recognised Specialist should be permitted to state quite truthfully that they specialise.

RE: Madness from referral practices

J G Wray — Sun, 04 Mar 2018 15:42:37 GMT

[quote user="Andy Moores"] I feel compelled to wade in and add to Rob and Andrew's voices to defend our side of the profession...[/quote]

Afternoon Dr M

Try this when moving between screens from a PMS

Why not put this on your website or in a letter/email to us?

[quote user="Andy Moores"]Emailed reports. Pretty sure this does not apply to us -our reports are generally emailed directly by the clinician, i.e. from their own e.mail address, and usually on the day of discharge or at least within 24 hours for 99% of cases. Sounds like you need to talk to the referral practice causing the problem Jonathan or change your email filters -or referral centre[/quote]

No it doesn't, nor does it apply to many other referral places. The one I had in mind has been approached more than twice over the years and the owner has sort of made an undertaking to sort it out in replying in this thread. On va voir.

[quote user="Andy Moores"]We try to be as transparent as possible about fees -I believe we were one of the first, if not the first, referral centre to openly publish a price list for common procedures on our website.[/quote]

Yup, you are and the charge for your surgical gloves is always a source of mirth. I'm with you in publishing headline fees and have been doing it for years. What's to lose?

[quote user="Andy Moores"]"They need us more than we need them". Sorry Jonathan, but this is very short-sighted. We all need each other, especially judging by the number of advice requests we get from GP vets.[/quote]

I didn't quite say this. It was more that you don't clothe your children without us. This is pretty well understood by most but not all clinicians, however the client care team can sometimes get this a bit wrong. As for mutuality, then it's there, but , as you know, we have the luxury of choice and that combined with a degree of dependence as mentioned, in my view, loads the dice in our favour. This isn't changing anytime soon. The outcome should probably be that you compete for our work in other ways. Your offer to have vets from referring practices in to see practice/shadow clinicians for instance makes you a little different.

As for phoning for advice requests, let's not dwell too much on how cases with long term prognoses that have been referred can experience a vacuum of input or dilution of responsibility from the referral practice as time passes - notably medical cases.

[quote user="Andy Moores"] And then there's the CPD, etc....[/quote]

Ah yes, your marketing - on to my least favourite subject. How are you going to handle your marketing post May 25th?

[quote user="Andy Moores"] I couldn't count the number of times have I been referred a case with a lameness that clearly localises to a particular area of the limb, but has had x-rays of every joint of the affected and the opposite limb performed, when a clinical examination should have identified the area of concern.[/quote]

I'm not letting you off this one. In general practice, first opinion practice we see cases that, at initial presentation, are not clear cut single limb, single focus ( e.g. joint) lameness. They may, for instance have bilateral lameness or multi site lameness following a trip, stumble or fall. That's the patient we radiograph in multiple sites and give NSAID to. You get to see the non-responsive patient where the problem has resolved to a solitary focus.

Clinical signs change.

[quote user="Andy Moores"]The cruciate case, to x-ray or not? Always before surgery (clearly). But most cruciate cases are obviously cruciate cases (clinical examination should tell you if there is a suspicion of OSA) and as a referral clinician I do not mind at all if the obvious cruciate case comes in without x-rays.[/quote]

I'm intrigued by this because I can see the immediate future including new therapies, that may allow interventions in general practice to modify what would otherwise be progression to stifle instability and degenerative changes. These therapies will require radiography and cytology as well as clinical examination.

[quote user="Andy Moores"]Theres no competition in the referral market". Certainly not true in the South East[/quote]

Quite

[quote user="Andy Moores"]At the end of the day the relationship between the primary-care practice and the referral practice should be mutually beneficial and respectful (in both directions). We both need each other. ... [/quote]

I think you know our practice point of view on this.

[quote user="Andy Moores"]There is nothing that bonds a client to a primary care practice more than a timely and good referral.[/quote]

Yes there is. Try a relationship of vet and client built over many years and across family generations, rather than the momentary quality of the referral experience. I'm treating unto the fourth generation for some clients.

[quote user="Andy Moores"] They will be forever grateful to you.[/quote]

Not necessarily. A discussion of examples is not for this forum.

[quote user="Andy Moores"]But if they end-up needing referral because their pet has been treated poorly prior to referral, you will probably never see them again.[/quote]

Please elaborate. I ask because this is how I see things. As the first opinion practice we have the relationship with the client which has earned trust and credibility. To them you have nothing, unless you are Noel Fitzpatrick, until we give you credibility in their eyes through making the referral. Clients haven't the faintest idea what the difference between one flavour of Specialist and another referral surgeon might be until we tell them. At that point you gain, but we don't lose if you keep your end up. So how do we lose, how do we make a poor referral?

RE: Madness from referral practices

Gillian Mostyn — Sun, 04 Mar 2018 12:20:55 GMT

[quote user="Andy Moores"]Wow! What a thread.[/quote]

Wow, what a comprehensive reply! It is lovely to hear from a specialist on this forum, and your input is much appreciated.

RE: Madness from referral practices

Andy Moores — Sun, 04 Mar 2018 10:05:26 GMT

Wow! What a thread. I feel compelled to wade in and add to Rob and Andrew's voices to defend our side of the profession...

1. The submission form. We have an on-line submission form too, but it's not compulsory. We will accept referrals however you want to make them -phone/fax/on-line/email. Our feedback is that lots of vets like the on-line process since they can do it straight from their computer in the consulting room. Our form has 25 fields. Not all are compulsory. I just tried it out and it took me less than 2 minutes to fill in. On the subject of the referral process, what we really love is a concise summary of the reason for referral in a referral 'letter'. This does not have to be a formal letter, it can be a paragraph or two within the clinical notes, but a summary of the condition, the reasons for referral and directed towards the referral centre. Sadly a lot of the time all we get is the basic clinical notes and we have to assume from these what the referring vet's thoughts are.

2. Emailed reports. Pretty sure this does not apply to us -our reports are generally emailed directly by the clinician, i.e. from their own e.mail address, and usually on the day of discharge or at least within 24 hours for 99% of cases. Sounds like you need to talk to the referral practice causing the problem Jonathan or change your email filters -or referral centre

3. Pricing. Let's face facts here. Multidisciplinary hospitals are expensive to set-up and run. We have greater nurse:vet ratios than in GP practice. We have a lot more kit and much of it is very expensive. We provide an on-site 24 hour service. We have higher staffing costs, -lots more nurses and high clinician salaries (this is not a choice, but a necessity - there is a shortage of specialists in the UK across many disciplines, and this has a huge effect on the salaries that clinicians can command -we will come onto that). In a discipline like orthopaedics it is possible to work as an ambulatory surgeon going from practice-to-practice but if your client wants...

A specialist surgeon working with a specialist referral nursing team in specialist facilities (a specialist surgeon working with nurses not used to specialist cases and in a standard operating theatre is NOT equivalent)
The ability for that case to see other specialists if necessary (a cardiologist to echo that murmur detected preoperatively for example, or a medic to asses the significance of concurrent health issues)
A specialist veterinary anaesthetist to run the anaesthetic and provide a comprehensive analgesia protocol
A high level of nursing and MRCVS cover over-night after surgery without the need to transport the patient to another centre soon after surgery (can anyone imagine for a second that they would stand for that if they had had surgery themselves?)
24/7 availability of a specialist after surgery if something goes wrong or you need advice or that patient needs to be re-examined at short-notice.

...then of course it is going to cost more. Some may not see the value over an 'in-house' referral but I bet your clients would if it was explained to them.

Whilst we are on the subject of pricing. There is a lot of discussion on the forum about the expense of referral services but when I talk to clients and GP vets often the services we provide are not dissimilar in price to those charged in general practice. Our pricing is pretty middle-of-the road for the level of service we provide, there are certainly more expensive referral centres. We will charge £3,150-3,850 for a TPLO depending on the size of the patient. That is all-in (fixed price, all costs for the surgery visit, also includes the 6-8 week check and VAT). There are plenty of non-specialist vets in non-specialist surroundings charging similar prices. We try to be as transparent as possible about fees -I believe we were one of the first, if not the first, referral centre to openly publish a price list for common procedures on our website.

Does any of this contribute to clinical outcome? Maybe not in many cases. But it certainly does in some. In the last 7 days I have treated a dog that had an osteotomy technique in general practice for a price similar to what a TPLO would be at our practice (so the owner tells me at least) which fell apart the night after surgery, resulting in a comminuted and complex fracture of the proximal tibia. For reasons that I can not go into here that dog may not survive this complication. A second case referred this week had an attempted 'toggle' procedure in general practice which could not be completed and ended-up with a poorly-executed femoral head and neck excision which will require revision surgery to rectify. Both cases had the funds and inclination for referral from the outset and if they had been referred I would be 99% certain that both cases would be happy convalescing at home right now, rather than facing an uncertain future.

4. Residents. As I have already alluded to, the UK has a shortage of specialists. Specialists are commanding ever-higher salaries and this is the biggest driver on referral price inflation. I believe that we have a duty to train future specialists and so we have residency training programmes. Residents therefore will see some cases. This is however always under the direct supervision of a specialist. This means every decision is made with the supervising clinician's input. Depending on the stage the resident is at during their training programme the supervising clinician may or may not meet the client at the initial consultation and the supervising clinician will always be available to that resident. For surgery cases, only when a resident is experienced in a procedure will they be allowed to run the surgery. As a business we obviously have a vested interest in making sure that our residents treat patients to the same high standards as our specialists would and so residents are very strictly supervised. Owners are always told in advance who they will see, and if they specifically request to see a particular clinician then 99% of the time we can accommodate this. Very rarely does a client have an issue with seeing a resident and it is always made clear that they are seeing a resident under supervision (which of course people are used to since it is not dissimilar to how the NHS works; many patients are seen by the Registrar rather than the Consultant).

5. "They need us more than we need them". Sorry Jonathan, but this is very short-sighted. We all need each other, especially judging by the number of advice requests we get from GP vets. On a typical day the Orthopaedic service at Anderson Moores answers between 5 and 10 email requests for advice. The other services will answer similar amounts, so that is probably 20-40 advice responses every day. We do this free-of-charge and without obligation. Some of those will end up in referral, some will not, but all responses are valued by the GP needing the advice. And then there's the CPD, etc....

I wonder if anyone would prefer the US situation where clients can self-refer without having to go through their 1st opinion vet?

6. Repetition of tests. Tests may be repeated for many reasons -they may not be up-to-date, imaging may not be of sufficient quality, they may not be available. They are NEVER repeated purely for financial gain and to suggest so is very inflammatory. In my discipline the most common reasons for repeating x-rays are poor positioning, poor exposures and lack of a sizing marker on digital x-rays. We almost always repeat x-rays for cruciate (TPLO) cases since we need to precisely measure the plateau angle and this requires precise positioning, precise centring, and for the hock to be included. Since we charge a fixed-price for the procedure though this has no impact on the cost of the referral.

Let's not pretend that 'unnecessary' tests do not happen in GP practice too. I couldn't count the number of times have I been referred a case with a lameness that clearly localises to a particular area of the limb, but has had x-rays of every joint of the affected and the opposite limb performed, when a clinical examination should have identified the area of concern. And, at risk of opening another can of worms, who routinely offers pre-GA blood tests to healthy young patients undergoing elective procedures? I don't.

7. The cruciate case, to x-ray or not? Always before surgery (clearly). But most cruciate cases are obviously cruciate cases (clinical examination should tell you if there is a suspicion of OSA) and as a referral clinician I do not mind at all if the obvious cruciate case comes in without x-rays.

8. "Theres no competition in the referral market". Certainly not true in the South East.

9. Sending cases back to the GP vet for surgery. Most clients do not want this. Once they have seen the specialist and had a diagnosis made 9/10 will want the treatment continued at the specialist centre (wouldn't you?). There are situations, financial for example, where we will send a case back to the GP practice for surgery but generally if a case is referred we will deal with it from diagnosis through to definitive treatment, which is what most owners want (and also most referring vets I believe).

At the end of the day the relationship between the primary-care practice and the referral practice should be mutually beneficial and respectful (in both directions). We both need each other. There is nothing that bonds a client to a primary care practice more than a timely and good referral. They will be forever grateful to you. But if they end-up needing referral because their pet has been treated poorly prior to referral, you will probably never see them again.

10. And finally... it's 'drawer', not 'draw'

Andy

RE: Madness from referral practices

Lucy Fleming — Thu, 01 Mar 2018 12:50:36 GMT

[quote user="Bob Russell"]Not a bad idea for a referral centre to produce a protocol that should result in images that will meet their criteria to prevent the need for additional X-ray exposures.[/quote]

This seems like an excellent idea! I can actually see Anthony's point (for once ) that it sometimes feels pointless radiographing these cases if you are fairly certain they will be repeated after referral. Being able to produce images that you know will help diagnose any unexpected nasties and thereafter be used to plan surgery by whoever carries it out would be nice!

RE: Madness from referral practices

Bob Russell — Thu, 01 Mar 2018 09:01:31 GMT

Dicom files can be manipulated on almost (if not all) imaging software. It is the industry standard.

Jpegs can be manipulated to some degree (contrast and zoom etc) but only to a limited extent especially if compressed to email.

I would happily receive constructive critisism regarding our radiographs!

RE: Madness from referral practices

Scarlett Creasey — Thu, 01 Mar 2018 08:52:23 GMT

[quote user="Clive Ansell"]

[quote user="Scarlett Creasey"]Some dogs arrived without xrays, great, some had radiographs previously and if they were submitted the surgeon would assess if they are of diagnostic quality etc and if they could calculate the angles and go from there. [/quote]

Very roughly, what percentage of radiographs submitted by first opinion practice were good? adequate? rubbish? of diagnostic quality? had to be repeated?

[/quote]

I don't think I could tell you the rough percentage as the orthopaedics rotation was only 1 week as part of an overall surgery rotation, so not sure I could give a true idea of numbers. I was involved with 4 stabilisations that week, 1 had diagnostic quality images, 1 had no radiographs at presentation, 2 had to be re-radiographed (the one with radiographs on the phone, the other the radiographs were taken approx 9 months previously).

I am not sure what software they use, but they use the images to calculate angles for cutting/rotating and also display the images with cutting guides in theatre.

RE: Madness from referral practices

Clive Ansell — Wed, 28 Feb 2018 20:55:19 GMT

Very roughly, what percentage of radiographs submitted by first opinion practice were good? adequate? rubbish? of diagnostic quality? had to be repeated?

RE: Madness from referral practices

Dagmar Steele — Wed, 28 Feb 2018 19:50:22 GMT

[quote user="Bob Russell"]

I suppose jpegs are easier to view on more devices but dicom files are much larger and more easily manipulated by their software. Not sure why they would prefer jpegs!

Most of the time our referral centres seem happy enough with the diagnostic value of jpegs.

[/quote]

Just to put into perspective on what level we're discussing at the moment: My daughter had her knee x-rayed last year. We wanted a second opinion because the radiologist got the knife out of his pocket a bit too quick for our liking. When I came round to pick up the x-rays as requested because they wouldn't send them themselves, I got handed a set of laser printer print-outs. Yes. Honestly. The clinic we went to for second opinion said they were basically useless (I could see that) but they were used to this practice. So. I'll leave that here and think about dcm vs jpg tonight ;-)

RE: Madness from referral practices

Bob Russell — Wed, 28 Feb 2018 13:07:39 GMT

I suppose jpegs are easier to view on more devices but dicom files are much larger and more easily manipulated by their software. Not sure why they would prefer jpegs!

Most of the time our referral centres seem happy enough with the diagnostic value of jpegs.

RE: Madness from referral practices

Evelyn Barbour-Hill — Wed, 28 Feb 2018 12:56:40 GMT

[quote user="Bob Russell"]We usually have to submit X-rays as jpeg's due to limitations of email but one allows us to upload dicom files via Dropbox.[/quote]

The last time I offered dicoms, I was told that they preferred jpegs. OK, wha'ever.

RE: Madness from referral practices

Niall Taylor — Wed, 28 Feb 2018 12:47:49 GMT

[quote user="Scarlett Creasey"]some clients turned up with the radiographs on their phones[/quote]

LOL!

RE: Madness from referral practices

Bob Russell — Wed, 28 Feb 2018 12:44:43 GMT

Not a bad idea for a referral centre to produce a protocol that should result in images that will meet their criteria to prevent the need for additional X-ray exposures.

We usually have to submit X-rays as jpeg's due to limitations of email but one allows us to upload dicom files via Dropbox.

RE: Madness from referral practices

Scarlett Creasey — Wed, 28 Feb 2018 11:26:28 GMT

Just finished the orthopaedic surgery rotation at RVC and of course saw a lot of stifle stabilisations.

Some dogs arrived without xrays, great, some had radiographs previously and if they were submitted the surgeon would assess if they are of diagnostic quality etc and if they could calculate the angles and go from there. Some need re-xrays, some were perfect and could be used from ref vets. Also depends on how the files are submitted I think, some clients turned up with the radiographs on their phones, and that's not really any good to the surgeon...

I am sure referral centres could tell you what they are looking for in the views and making diagnostic quality images.

RE: Madness from referral practices

J G Wray — Wed, 28 Feb 2018 10:34:45 GMT

An example of email madness probably, but not certainly, from CEVA rep

rep.name=ceva.com@mail205.atl81.rsgsv.net

Straight into the filter

RE: Madness from referral practices

J G Wray — Wed, 28 Feb 2018 09:43:06 GMT

[quote user="Dinu Catilina"]Nice to see that a topic that might have had some influence on some referral practices it's turned in to irrelevant gibberish. [/quote]

Well, as OP, I think I've got what I set out to get. On va voir.

On the CCL thingy, why wasn't cytology mentioned, particularly at the dawning of an age of new therapies, stem cell, platelet derived growth factor etc.?

RE: Madness from referral practices

Dinu Catilina — Wed, 28 Feb 2018 09:10:45 GMT

Nice to see that a topic that might have had some influence on some referral practices it's turned in to irrelevant gibberish.

RE: Madness from referral practices

J G Wray — Wed, 28 Feb 2018 08:00:39 GMT

Barbour-Hill, it's your turn to explain the noun as an adjective, the adjunct noun, as you were taught by Nicholas Nickleby at your brutal Yorkshire boarding school, as opposed to the adjectival inflection say in "drawer instability".

RE: Madness from referral practices

Dagmar Steele — Wed, 28 Feb 2018 07:10:42 GMT

[quote user="Chris Geddes"]

[quote user="Evelyn Barbour-Hill"]draw[/quote]

I had it in my head that nobody knew the origin of the term and that it either meant that the movement was like that of a drawer, or that draw meant "pull or drag at something" - so I have been tolerant of either spelling.

A quick check through textbooks on my shelf, Pubmed and Google suggests that the vast majority of people in both the human and veterinary literature go for drawer rather than draw.

Do you have evidence that draw was the original term used Evelyn?

Chris

[/quote]

Maybe it helps to compare how it's called in other languages. In Germany it's called the Schubladen-Test. Which translates into drawer-test, not draw.

RE: Madness from referral practices

Evelyn Barbour-Hill — Tue, 27 Feb 2018 22:35:45 GMT

[quote user="J G Wray"]Barbour-Hill you claim respect for the English language and in apologising you are conveying a mood not a tense. So what verb form do you use?[/quote]

Please sir oo sir oo gosh sorry sir.

I will (correct) write out my corrections three times chiz and all shall (correct) be forgiven.

RE: Madness from referral practices

Rob Loxley — Tue, 27 Feb 2018 22:13:09 GMT

[quote user="Gillian Mostyn"]

[quote user="Niall Taylor"]If an owner knows their dog is suffering terminal cancer rather than an eminently fixable ruptured ligament their preferred course of action is likely to be different.[/quote]

You're right...in an ideal world, with no cost implications, a set of radiographs is ideal to rule out other causes before referral. However, I do think that in most cases, signalment, a complete history and clinical exam will differentiate most cases.

[/quote]

And therein lies the art of veterinary medicine, not some catch all protocol that says do this or don't do that. But there's enough stories here that even with lots of experience you can still end up getting bitten