Deskilling

RE: Deskilling

Arlo Guthrie — Tue, 25 Feb 2020 17:10:15 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/28891/deskilling/219798"]Not allowed to "like" or "agree" but must do both completely.[/quote]

I've switched the likes off temporarily, whilst we get the ruddy thing fixed in Safari!

RE: Deskilling

Anthony Todd — Tue, 25 Feb 2020 15:50:28 GMT

[quote userid="6550" url="~/001/nonclinical/f/life-in-practice-discussions/28891/deskilling/219800"]More expensive may well not be better. It may also not be in the best interests of the patient or owner.[/quote]

Much better put and adds to my point!

RE: Deskilling

Bob Russell — Tue, 25 Feb 2020 15:23:34 GMT

Rubbish!

Best practice should lead to best success rates. If not it is unlikely to be best practice.

It is often the case that best practice and success rate can be a lot cheaper than fannying around trying this and trying that.

More expensive may well not be better. It may also not be in the best interests of the patient or owner.

I think I will continue to think in terms of best interests rather than best practice or gold standard. That is what I am paid to do IMO!

RE: Deskilling

Anthony Todd — Tue, 25 Feb 2020 15:09:59 GMT

Not allowed to "like" or "agree" but must do both completely.

Ironically the choice is nothing about "best practice" or success rates , just about money in most cases.

More expensive is the better.

RE: Deskilling

Colin Cameron — Mon, 24 Feb 2020 12:50:40 GMT

Hi Neil

I will base my comments around surgery, my own particular interest in general practice, but appreciate it will apply to any discipline within our profession.

This profession has been 'de-skilling' vets in practice since before you qualified! It accelerated once practices could be owned by 'non-vets', which started around that time. I am constantly puzzled why so many relatively straightforward procedures 'must' be referred......why must? Also if all these younger vets suddenly become specialists in enormous referral centres, how will they get any work at all without general practitioner vets referring cases. A case of geese and golden eggs,perhaps?

Some are not exactly enthusiastic to learn these procedures but many more are keen as mustard, I hasten to add. Almost an approach of 'why learn this at all as I will always refer to a specialist'. How do any of these vets become specialists without a good grounding in basic techniques, progressing to more advanced procedures before tackling the referral stuff?

Over the years I, and many others vets in practice, have performed many thousands of operations of all different types but now some of these younger vets suggest we should not be doing any of the 'advanced procedures', as they are a job for specialists. Why? Surely a referral case is simply one beyond the expertise of the referring practice or that the practice has the expertise but is lacking the time, equipment or facilities needed?

I am well aware of limitations in practice and regularly refer cases across all disiplines as appropriate, and will continue so to do.

It must be remembered that no vet, whether GP or specialist gets it right every time and simply being a specialist does not automatically make you better, or being a GP vet make you worse, than anyone else.

Are we, as a profession, developing feet rather too large for our footware and do we need to get back to our core activities where, I guess, over 95% of cases we see are fairly straightforward?

Are we making a lot of hitherto relatively straighforward procedures overly complicated so need referring? Are we becoming more and more reluctant to do anything in case the legal beagles chase after us?

Have we gone too far down this slippery slope or can we start re-skilling vets in general,practice so they begin to refer cases when they 'choose to' rather than because thay have no choice and 'have to'.

I have, for a long time, been concerned about this de-skilling and in my own small way I have tried to encourage younger vets to develop good techniques across all disciplines in the belief that if they learn the appropriate skills they will be able to do more within a practice setting, refer less and hopefully have greater professional satisfaction. It may even reduce the number of younger vets leaving the profession.

Just spotted your other post and wondered why would an anal sac removal ever need to be referred?

I am not against specialists but am very much against the systematic de-skilling of Vets in general practice.

I wait to be shot down in flames!

RE: Deskilling

Carol Gray — Fri, 21 Feb 2020 11:02:27 GMT

Number of referral practices increasing (latest RCVS figures show 6.4% of profession working in referral practice, https://www.rcvs.org.uk/news-and-views/news/surveys-offer-insights-into-veterinary-and-veterinary-nursing/) so they tend to be "accessible" for most clients. The key is client consent. Open and honest dialogue with clients as to level of experience in performing the proposed surgery, risks involved, comparative costs at GP practice vs. referral practice, and let the client decide. Shared decision-making!

RE: Deskilling

Julie Innes — Fri, 21 Feb 2020 09:00:26 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/28891/deskilling/219652"]Just imagine if they approve telephone consults.....[/quote]

At least telephone consults will no doubt be recorded!

RE: Deskilling

Anthony Todd — Wed, 19 Feb 2020 16:53:23 GMT

[quote userid="7811" url="~/001/nonclinical/f/life-in-practice-discussions/28891/deskilling/219637"]clients tell me a completely different story to the one in the notes[/quote]

Just imagine if they approve telephone consults.....

RE: Deskilling

Julie Innes — Tue, 18 Feb 2020 15:46:57 GMT

Totally agree, Neil. Genuinely, I never ever criticise another vet, even if I can't follow his/ her reasoning, as I always think "there but for the grace of God..."And I've had clients tell me a completely different story to the one in the notes, or the phone call I was listening in to.

RE: Deskilling

Neil Wheadon — Tue, 18 Feb 2020 11:54:45 GMT

[quote userid="7811" url="~/001/nonclinical/f/life-in-practice-discussions/28891/deskilling/219589"]Surgery went ok, dog was fine 2 days post op check, then apparently it licked its wound, which broke down. Trip to emergency vets, followed by surgery there by the specialist, at a cost of thousands. Discovered his insurance would only cover £500. Dog didn't make it. Cue it all being my fault, barrage of phone calls, abuse, lawyers letters. The VDS were great, and he got nothing, but it was hugely stressful, and they asked me if I'd offered him referral to a "more experienced surgeon" [/quote]

As a locum, I see loads of things, take this morning. A recurrent ulcer, various treatments tried, so I Schirmer test stripped it, and it was 1mm. There are a number of responses, but take the 'people in greenhouses shouldn't throw stones approach'

A doctor friend recently said that consultants in hospitals will ask a GP 'How did you miss that?' The answer is often that disease takes time to fully manifest itself.

A second opinion is a chance to look clever. You can see the things that have failed and can usually try something else

The golden rule surely is 'don't drop the first vet in the soup'

I suspect that the above was not because of the operation, but because something was said. 'Be kind', it could be you next time. This thread has revealed another implication, it stops people stretching themselves.

Neil

RE: Deskilling

Dagmar Steele — Tue, 18 Feb 2020 09:38:56 GMT

Log on youtube, there's a ton of videos on all kind of surgery!

RE: Deskilling

Anthony Todd — Tue, 18 Feb 2020 08:44:04 GMT

As a start a really, experienced SA surgeon could star in a video of routine ops mentioning all the tips and tricks.[financed by a drug Co.]

Starting with the [absolute] key incision position for a C/S, for example, adding all the other things that are learned only by experience.

As far as I know there's nothing now?

PS Post it on here and I'm sure others would add useful advice and tips.

RE: Deskilling

Anthony Todd — Mon, 17 Feb 2020 15:17:44 GMT

[quote userid="8958" url="~/001/nonclinical/f/life-in-practice-discussions/28891/deskilling/219557"]

There seems to be an agreement that it's happening but we need solutions and encouragement to recent graduates to try things rather than endlessly criticise them saying they are lacking basic clinical skills.

Thomas has bitten as most of us do, and all that does is distract, dilute and ultimately destroy a thread.

[/quote]

I am not, repeat, not, criticising new grads, never have, we all were one, and I was just as totally inept!

I'm just stating the bleeding obvious, that new grads have a lot of knowledge but practical things, like surgery, dealing with clients, and related interpersonal skills, cannot be taught they have to be learned.

They are only learned by practice ie doing things again and again.

This is why I have suggested some sort of internship or mentoring and, yes, I've suggested this again and again.

This is NOT a criticism, just a fact!

RE: Deskilling

Bob Russell — Mon, 17 Feb 2020 12:19:22 GMT

The trouble is that the nice shiney, expensive referral centres must be paid for!

Is this investment leading to a steady draining of the coffers of 'normal' practices?

Referrals at £4000+ are not realistic for many pet owners therefore offering it can increase the distress of these clients. A distressed client is more likely to complain therefore vets are put in a Catch 22 situation.

I use the phrase 'realistically what sort of budget do you have?' At this point we only deal with treatment options that owners can afford and reduce the guilt factor.

I agree with the DC comments suggesting referral should have been offered but the DC does have to appreciate this is not an option for many and inappropriate for others therefore will be declined.

RE: Deskilling

Arlo Guthrie — Mon, 17 Feb 2020 12:05:17 GMT

[quote userid="18902" url="~/001/nonclinical/f/life-in-practice-discussions/28891/deskilling/219591"]There are lots I would love to try, but if stuff goes wrong clients and even (my feelings/fear. May/may not be true)RCVS always come with the question of why didn't you refer earlier. [/quote]

I think this is really sad: that as a not-so-long-ago-grad, you feel like that. I really do. But it does strike me as something that it is not too late for the profession to do something about.

RE: Deskilling

Mary Lu — Mon, 17 Feb 2020 11:45:42 GMT

As a 2016 grad I completely agree with you. There are lots I would love to try, but if stuff goes wrong clients and even (my feelings/fear. May/may not be true)RCVS always come with the question of why didn't you refer earlier. And although I agree with RCVS that one has to recognise ones own limitations, there is a degree of deskilling that occurs as a result and before you know it all interesting cases go to referral - contributing to dissatisfaction with the profession.

The people I know who are getting the support to grow those practical skills either 1. Work in charity or low income area where referral is not possible 2. Have a boss who are very skilled from the old days of giving everything a go, and are willing to share that knowledge.

RE: Deskilling

Julie Innes — Mon, 17 Feb 2020 09:48:52 GMT

The sad fact is that 25 years ago when I first qualified I was happy to have a go at pretty much anything (had no choice!) but now.... I am far more cautious about what I will attempt these days. The last procedure I attempted that was slightly outwith my comfort zone but which I had performed successfully a couple of times previously was a perineal hernia repair. I was reluctant to do it all, and gave the owner all the potential complications and warnings, but they wanted the surgery, as they felt the alternative was euthanasia. Surgery went ok, dog was fine 2 days post op check, then apparently it licked its wound, which broke down. Trip to emergency vets, followed by surgery there by the specialist, at a cost of thousands. Discovered his insurance would only cover £500. Dog didn't make it. Cue it all being my fault, barrage of phone calls, abuse, lawyers letters. The VDS were great, and he got nothing, but it was hugely stressful, and they asked me if I'd offered him referral to a "more experienced surgeon"

Now, I am far more guarded. I distrust people to be understanding when/ if things go wrong. Not worth the stress and hassle

RE: Deskilling

Edward Jones — Mon, 17 Feb 2020 09:01:31 GMT

[quote userid="6353" url="~/001/nonclinical/f/life-in-practice-discussions/28891/deskilling/219555"]On a least three occasions I received phone calls (nothing in writing/email, nothing recorded) telling me 'that's not the way things are done'. [/quote]

After communications like this it's worth considering following up with an email clarifying and confirming what was said. Phoning you to keep communications off-the-record in this manner is an abuse of authority, and cowardly.

RE: Deskilling

Neil Wheadon — Sat, 15 Feb 2020 12:32:28 GMT

CAMPING = TESTING

See above (quite an amusing I can't edit that with Safari browser)

Neil

RE: Deskilling

Neil Wheadon — Sat, 15 Feb 2020 12:31:01 GMT

[quote userid="6297" url="~/001/nonclinical/f/life-in-practice-discussions/28891/deskilling/219562"]What I have noticed is that there seems to be a greater willingness to work-up medical cases, including unusual cases, than there is to try anything challenging surgically.[/quote]

That's very true

I have also noticed that a lot of newer graduates are very good at ultrasound scanning and I constantly defer to their expertese

I feel it's a case of 'do no harm' where in it's very nature surgery is invasive and has the potential to do so, yet as David has pointed out the body has a tremendous ability to cope with surgery and many of the middle tier operations definitely fall into that category in my opinion. Maybe it is fear and dodgy statistics? I vividly recall a London Vet Show presentation where they said that 9% of enterotomies broke down, that would put the fear of god into me, yet I've never had one and I can't remember seeing one. Maybe like the statistics on pre-anaesthetic blood camping we need a proper revue of first opinion cases, though the Universities are doing this now which is a great thing.

Neil

RE: Deskilling

Thomas Johnson — Sat, 15 Feb 2020 11:56:15 GMT

[quote userid="8958" url="~/001/nonclinical/f/life-in-practice-discussions/28891/deskilling/219557"]This thread has had some tremendous replies not least from Chris. There seems to be an agreement that it's happening but we need solutions and encouragement to recent graduates to try things rather than endlessly criticise them saying they are lacking basic clinical skills.[/quote]

What I have noticed is that there seems to be a greater willingness to work-up medical cases, including unusual cases, than there is to try anything challenging surgically. It's some time now since I graduated, but my experience at vet school was that when we were on the medicine rotations the students, with support from the vets, made the decisions about what investigations were needed and what treatment to give, which probably gives a lot more confidence after graduation in managing medical cases, whereas actual surgical experience was a lot more limited.

RE: Deskilling

Eamon McAllister — Sat, 15 Feb 2020 11:42:06 GMT

Chris Barker’s last post confirms my long held opinion that (cliche alert) the RCVS is not “ fit for purpose”

RE: Deskilling

Neil Wheadon — Sat, 15 Feb 2020 10:59:21 GMT

Anthony, this is a direct plea.

Please can you think before you type, many of the comments you are putting forward could be a copy and paste from previous discussions. In effect so many discussions end up going down the same line....yours.

This thread has had some tremendous replies not least from Chris. There seems to be an agreement that it's happening but we need solutions and encouragement to recent graduates to try things rather than endlessly criticise them saying they are lacking basic clinical skills.

Thomas has bitten as most of us do, and all that does is distract, dilute and ultimately destroy a thread.

Neil

RE: Deskilling

Thomas Johnson — Sat, 15 Feb 2020 10:52:31 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/28891/deskilling/219524"][a 15yo cat not eating but drinking a lot with grotty teeth and losing weight......what would you recommend??][/quote]

Okay, I'll bite. I assume you've given this as an example of not needing further diagnostics as it's got chronic kidney failure, but I would want to run bloods on this cat. It could have awful dental disease and the pain is affecting its appetite and the inflammation is causing pu/pd, a small proprotion of hyperthyroid cats present as inappetant, I suspect due to nausea, it could be diabetic ketoacidotic, it could have alimentary lymphoma.

RE: Deskilling

Chris Barker — Sat, 15 Feb 2020 10:38:01 GMT

[quote userid="12375" url="~/001/nonclinical/f/life-in-practice-discussions/28891/deskilling/219542"]I'm not sure I agree with you that it is vital for active practitioners to stand for council. As far as I can see all the decisions are made ‘in committee’ (often in secret ), then rubber stamped at council.[/quote]

Just to clarify how the RCVS works The Committees are made up from Council members, with a mix of vets, vet nurses and appointed lay members Who sits on each committee is to a degree dependent on their skill-sets, previous time served on the committee, but ultimately the choice e is controlled by the Officers (primarily this year's President) and the CEO. Initiatives derive from the 'strategic plan' - a long involved document, a statement of intent within which sometimes quite innocuous sentences can hide profound purpose.... Once the plan is accepted the initiatives are driven forward by the Executive.

But it can be very difficult to identify who is the primary driver, the initiator behind the process. When I sat on Standards we were presented at each meeting with an agenda and papers/proposals to discuss Some of the items arose from feedback from previous PIC/DC decisions, some fom legal officers who had noticed a potential conflict between different existing points of advice etc But they emerge from discussions between the Committee chair, the legal officers (the Registrar and other Solicitors working for the legal dept/Professional Conduct) and (I would assume but cannot prove) the Officer team/Operational Board.

This system persists even as Council shrinks in size and the OB has been disbanded, leaving committee members feeling they are contributing little until ultimately papers arrive before them. As I say I have made attempts to initiate change - I managed to raise the issue that owners had responsibilities towards their animals just as much as do their vets, and a statement was included on the website despite resistance from the then CEO. Though it was well hidden.... Only after the 24/7 consultation was this statement adopted formally, and it now sits as part of the Supporting guidance to the Code. And I have highlighted my ideas regarding the encouragement of MsRCVS to develop their clinical and surgical skills within first opinion practice rather than referring everything. But it is incredibly difficult to start an initiative by yourself, unless you are ready to commit big time to the RCVS and work your way up the tree into the Officer Team...

I'm afraid that during our former CEO's time Council did become a PR exercise - the top table wanted to present a unified front - and when I did raise my head above the parapet at Council to question a decision made by a delegated committee for final signing off this sometimes caused upset. On a least three occasions I received phone calls (nothing in writing/email, nothing recorded) telling me 'that's not the way things are done'. Gratefully there are still those who will speak up at Council when we have an 'Emperor's New Clothes' situation, where proposals brought forward have significant consequences which seem to have been ignored. But we need a breadth of members of different experience - no one person can 'see' all the problems/consequence of an initiative My personal rule when assessing any new initiative is 1. Is it warranted? 2. Is it proportionate? 3. Is it deliverable by those in Practice? If it isn't, then I speak up, whether it be in committee or in Council

I've done what I can and am leaving before cynicism paralyses me. But it is important, it is vital that people who understand the pressures felt by four-line first-opinion practitioners are on Council If you don't make the effort than you cannot complain about the consequences