Cert AVP

Re: Cert AVP

Malcolm Ness — Tue, 13 Apr 2010 08:56:30 GMT

Robert,

Not sure you got the meaning of what I wrote as yopu seem to be taking a rather combative stance while making much the same points as I did.

Like you, I believe that vets should "discuss the available options" and that is what I mean by obtaining properly informed consent. It is wever, essential that all the options and not merely the personally profitable or "in-house achievable" options are discussed. On one hand, I remain a passionate believer that all vets should be encouraged and allowed to continually improve their clinical ability, expertise and repertoire but this must be done within the limits of what is best for the patient and desired by the client. Far too often I come across cases that have undergone uneccessary, inappropriate or badly executed surgery typically because a surgeon has had an "excess of confidence over competence" and has failed to have the kind of options discussion you describe. Too often, the client has been led to believe that the only difference between in-house surgery and referral is the price omitting to mention that a diplomate surgeon (even the minimally qualified surgeon that has just finished a residency and passed the diploma exam) is rather differently able and qualified than they.

Unfortunately, there is a body of opinion that wants to react to this by ever increasing regulation of the type that would impact seriously on the type of cash strapped clients and patients to which you refer.

In my "real world" (the industrial NE of England) my referral vets would typically not reach for the euthatal but instaed reach for the telephone and we would discuss options that might include conservative/medical management of a fracture; "talk through" of a surgery that they wouldn't have felt able to do alone; taking the patient as a teaching case for the benefit of the referring vet or one of our residents. It is often possible to get a win-win out of these situations.

Re: Cert AVP

Bob Russell — Mon, 12 Apr 2010 13:38:06 GMT

Sorry - I think it is about time some reality is introduced to this discussion. Our clients often have limited funds available to them. In our practice we refer regularly where I feel someone else can do a significantly better job than I can as a single-handed practitioner.

Most animals will not get 21st century treatment, their owners cannot afford it. Many are unable to fund a £3000-£5000 investigation/treatment, it is a non-starter. This does not mean we do not do the best we can but often the 'ideal' human standard options are not open to us. Some would say nor should they.

Our job is to deal with every case as best we can to ensure the best possible outcome for our patients and their owners - the idea that all pets should be seen by vets with years of further formal study is farcical and unrealistic.

All should be seen by vets that know their limits and discuss the available options with owners. I am a 'minimally qualified surgeon' by your definition but after 25 years in practice I can cope with much of what gets thrown at me on a daily basis. I have often had to cope with doing procedures I have been uncomfortable doing, knowing my inexperience is an issue. Do we automatically reach for the euthatal if an impoverished owner presents a difficult case and cannot afford referral? No - we get on and do what we can for a very reasonable price. Not perfect but the real world!

Re: Cert AVP

Rob Reid — Mon, 12 Apr 2010 11:31:49 GMT

[quote user="Emma Howarth"]

Rob,

Don't know if you are already aware, but maybe your boss might be interested in signing your practice up for the RCVS library? It gives access to a lot of the research resources we can use through Athens (e.g Wiley Interscience and Science Direct) and also has access to other useful veterinary journals e.g. JAVMA.

[/quote]

Thanks for that Emma - that's handy to know

Re: Cert AVP

Hannah Wynne Richards — Mon, 12 Apr 2010 09:58:12 GMT

Malcolm. RCVS are highly unlikely to take a more robust view-because at least 12 Council members are University appointees, and they don't want senior staff to actually have to see referral cases, or closely supervise residents

Emma. The Middlesex fee included access to RCVS library-then half-way through the year, access to Science Direct was suddenly stopped-very annoying

Wynne

Re: Cert AVP

Emma Howarth — Sun, 11 Apr 2010 20:04:25 GMT

[quote user="Hannah Wynne Richards"]

Bradley and Emma

Some of the GP Certs are monitored by Uni West of England, and having gained the Cert, and written an extra essay, it will count as a 10 credit module-so I suppose a GP Cert is worth 1/6th a Cert AVP

Wynne

[/quote]

Thanks for that Wynne - I thought I'd read it qualifies somewhere. Always nice to know I'm not losing my marbles!

Rob,

Re: Cert AVP

Bradley Viner — Sun, 11 Apr 2010 17:21:13 GMT

Hi Malcolm.

In response to your critique of my earlier comment:

1) As a relativist, I suspect (but do not know for sure!) that most things are a matter of opinion rather than fact, just some more certain than others. I would be interested to hear your opinion of how you think that case reports and written exams can evidence surgical skill.

2) Just because I think there were significant problems with the old Cert, it does not mean that I do not think it was worthwhile or served an important purpose. Despite being involved in its evolution, I could vociferously criticise aspects of the new CertAVP (and I have, here) but that does not mean that I don't think it is more fit for purpose at the current time than what went before.

I'm a strong believer in continual improvement. I know you must disapprove of that because it involves experiential learning, and admitting that everything you cherish is not likely to be perfect.

Looking forward to the next brickbat.

Re: Cert AVP

Malcolm Ness — Sun, 11 Apr 2010 16:56:23 GMT

I think it is a great idea, but you have already pointed out some of the problems. First, outcome analysis; second blank numbers don't say everything. "Surgeons know how to operate, good surgeons know when to operate and the best surgeons know when not to operate"

A slightly scary fact was reported to me recently, that almost all of the total hip replacement surgery in dogs in US is done by a small handful of hip surgeons, meaning that a lot of other hip surgeons are doing fewer than 5 cases a year. The same is almost certainly true in UK and I guess that that is the thrust of your post. Not at all sure what the solution is - I am doctrinally oposed to any kind of regulation if it can be avoided. It is noteworthy that common law as well as the guide to professional conduct is keen on the concept of informed consent. To my mind, a vet cannot really claim to have obtained properly informed consent for an operation unless the client is aware first of that surgeons level of experience, qualification and expertise as well as the availability of other options such as having the surgery done by another surgeon with more experience, qualification and expertise. If RCVS took a more robust view on this, perhaps the problem would go away.

That way, there exists a route for less experienced surgeons to develop while protecting the interests of clients and, importantly, patients. The self-appointed experts would suffer but I don't see that as a problem.

Before anybody misinterprets what I am suggesting, I am not, and never would be, suggesting that some ops are "referral only" procedures. However, I do believe that much surgery is currently performed by vets who have insufficient experience, training and expertise and that information is with-held from the client.

The days of the omnicompetent veterinary practitioner are long gone. Bear in mind that by the time my current resident sits his surgery diploma exams, he will have spent almost as many hours on his 3 year SA surgery residency as he spent studying 5 years for his BVMS degree. If he was in the US, passing his diploma would earn him a T shirt bearing the logo "Minimally Qualified Surgeon"

Re: Cert AVP

Malcolm Ness — Sun, 11 Apr 2010 16:31:38 GMT

[quote user="Bradley Viner"]Case reports do not in themselves evidence it, neither do written papers. Cadaver surgery might, especially if you habitually operate on dead patients. [/quote]

You really must stop passing off opinion as if fact.

[quote user="Bradley Viner"]Finally, neither I nor to my knowledge other members of what was the SPVS Masters/Doctorate group (that has now evolved into Vet Learning) have been vociferously critical of the old certs.[/quote]

!!!!!!! but you have just suggested that the basis upon which the Cert was awarded or not was/is utterly unreliable.

Re: Cert AVP

Hannah Wynne Richards — Fri, 09 Apr 2010 10:45:06 GMT

Bradley and Emma

Some of the GP Certs are monitored by Uni West of England, and having gained the Cert, and written an extra essay, it will count as a 10 credit module-so I suppose a GP Cert is worth 1/6th a Cert AVP

Wynne

Re: Cert AVP

Rob Reid — Thu, 08 Apr 2010 21:35:42 GMT

[quote user="Emma Howarth"] I've done my A and B-SAP modules with the RVC online and agree with you that they represent good value for money. The online learning support is still very much evolving though, which I guess goes back to the universities not having much time to prepare for the new qualifications![/quote]

I have to confess that I haven't used the Blackboard much and it seems that most other users are the same. What has been great though is the ATHENS access - this has proved invaluable so far. The nearest vet school library is 2 & 1/2 hrs from me so I would really have struggled without it.

The other good thing is that my boss seems pretty impressed with it as well and is talking about signing the practice up to it permenantly after I have (hopefully!) completed the course.

Re: Cert AVP

Emma Howarth — Thu, 08 Apr 2010 19:24:45 GMT

Bradley

I have a vague recollection of reading something on the back of a mailing from them...although it is VERY possible that I dreamt it!!!

Rob

I've done my A and B-SAP modules with the RVC online and agree with you that they represent good value for money. The online learning support is still very much evolving though, which I guess goes back to the universities not having much time to prepare for the new qualifications!

Re: Cert AVP

Bradley Viner — Thu, 08 Apr 2010 14:02:33 GMT

Hi Emma

I think the rumours you heard about the existing Improve modules being accredited for part of a CertAVP module are incorrect. I certainly have heard nothing along those lines and it seems very unlikely, but as I said, they may well be offering CertAVP courses in conjunction with an RCVS accredited University. I would welcome that, although I am curious to see how they will cope with the confusion that will result from them offering two different "Certificate" courses.

I agree very strongly with what you have said about professional development - in fact Chapter 7 of my new book entitled Success in Veterinary Practice is all about postgraduate learning and how best to develop it.

Re: Cert AVP

Emma Howarth — Thu, 08 Apr 2010 11:58:03 GMT

I could be wrong, but I vaguely remember reading somewhere recently that a limited number of the Improve Modular "certificate" courses may be gaining RCVS recognition (if passing the whole thing), but only as ONE 10 credit module. In other words, they would only contribute 1/6th towards the course work for a Cert AVP. This would therefore represent a pretty expensive way of trying to complete a certificate! I think they are a valuable way of expanding your knowledge but I agree that the fact that they are called a Cert GP is extremely confusing, especially for clients (and especially given the Cert AVP GP) as clearly they are not in any way the equivalent.

I think maintaining a simple tiered system of qualifications is the best way forward: this makes it simple for members of the profession (allowing them to use their initiative to refer clients to the appropriate clinician and explain exactly what they are getting) AND protects those who have achieved the highest accolades. This does means that all subjects (e.g. opthalmology) need to be available at each level to give veterinary surgeons a chance to pursue their interests and decide how far up the post-graduate ladder (if at all) they want to climb!

Personally, one thing I would really like to see within the profession is better access to careers advice. Not only at undergraduate level (don't know if this is routinely provided now, but it wasn't when I was at uni), but also after graduation. After all, if we select for the most super-intelligent candidates to enter the profession and then give them a job rather than a career is it any wonder that they become disillusioned? If people had more of an idea of what they wanted to achieve (and the best way to go about doing this) then they would be more motivated to get there. Personally, I expect the drop out rate for the new certificate will be similar to the old one; they are something which are often started with good intention and easily dropped when the amount of effort required is balanced against other commitments (I know. I've been there before). It would have been great if someone had pointed out to me years ago it would be a good idea to knuckle down before having kids!

Re: Cert AVP

Vikki Halliday LLB — Thu, 08 Apr 2010 08:53:41 GMT

[quote user="David Strong"]A register of 'really decent surgeons' as well as a register of specialist surgeons? [/quote]

It exists. It's called the PSS.

Re: Cert AVP

David Strong — Wed, 07 Apr 2010 21:32:04 GMT

With all of the discussion put forward over methods of assessment and who should be accepting referrals etc, I'd be keen to open a wasps nest and suggest that it would be great to have an objective log of the total number of certain proceedures and the frequency of which these certain proceedures are conducted by certain surgeons... a kind of league table if you will.

For instance... a referral 'specialist' with a really great depth of knowledge might not be as fluent in certain proceedures or conduct these as frequently as another, apparently less qualified individual. A very open question... who would you rather refer to? How would you know that there is a 'non-specialist' who is very fluent in certain proceedures just around the corner?

For a given subject area a cert would appear to be a cert and a RCVS or European diploma would appear to be a RCVS or European diploma. There lacks distinction between surgeons on the same rung of the ladder, where clearly a means of distinction could be created and prove useful to referring vets. By means of example... If there are two surgeons with identical qualifications, one who's main caseload is cutting backs and the other who is mainly conducting ccl work, an objective means of selection could be very useful in considering who to send your spinal or your more complex ccl cases.

Would the Specialists hate the comparison that might then arise on the potentially more level playing field with cert holders and the very experienced surgeons (I currently do not qualify) who have no inclination to obtaining further qualifications? Or would this be seen as health competition in a more free market? A chance for those with the right caseload to truly shine! I'm sure the likes of Malcolm would relish this as it sounds as if he is kept very busy and are still likely to come out ontop!!

It could be argued quite rightly that numbers do not necessarily equate to quality, but the same quality can often be achieved by surgeons who haven't got all of the extra qualifications.

There is also the problem that a few years after obtaining a qualification an individual's caseload has often changed and the qualification itself is no longer an accurate reflection of an individuals competancies. I guess this is one of the reasons that the RCVS Register of specialists is maintained as it is. An ops log could be really useful.

Although it may involve more data logging, could a similar scheme to expanded to folk lower down the ladder? A register of 'really decent surgeons' as well as a register of specialist surgeons? Would this give greater value to any cert holder in the longer term as well if he or she gets too caught up in practice ownership to be able to take the next step and undertake a residency?

To have a freely available ongoing ops log of sorts could still be very useful for referring surgeons and act to improve benchmarking as an over-all package (ie not to be taken in isolation). Numbers alone would have to be taken with a pinch of salt in the same way as individual qualifications sometimes are. Any thought?

Re: Cert AVP

katja wagner — Wed, 07 Apr 2010 21:14:42 GMT

Dear Bradley,

many thanks for your answer, i know that you are kind of standing on the other side of the fence which makes it so interesting to get your opinion. I was toying with the idea of their certificate because i wanted to gain deeper knowledge in certain areas and the courses seemed appealing but i find it rather expensive. what puts me off big time of the certificates offered by RCVS are the A/B syballus ,i am afraid not real able to find much interest in those topics.

anyway ,i would have never seen any of the certificates as a way to "specialise", just as part of my cpd.

many thanks

katja

Re: Cert AVP

Bradley Viner — Wed, 07 Apr 2010 20:49:18 GMT

I have refrained from responding to this previously because I am involved in Vet Learning which is a competitor to Improve in some areas. However, I am happy to give my unbiased impression from my knowledge of their courses (from the information they provide and indirectly as i have never been on one myself).

I think they are a quality CPD provider and a lot of their teaching is excellent. I am just sad that they made a commercial decision to muddy the waters by offering "Certificate" qualifications that are not RCVS approved and are not equivalent to either the old or the new Certs. I think this is very misleading, although they have every legal right to do so. It is possible that in the future they may offer modules for the RCVS CertAVP in conjunction with a University so you should ask them about that.

By all means do on their courses, and if you wish, sit their exams. I am sure you will improve your practice as a result. But do not be fooled into thinking that the standard of their "Certificate" is the same at the RCVS ones, old or new. Nor can they be entered onto the RCVS Register.

Re: Cert AVP

katja wagner — Wed, 07 Apr 2010 20:14:00 GMT

Dear Malcolm, dear bradley,

i would very much welcome your opinion about certificates of improve international.

thanks a lot

katja

Re: Cert AVP

katja wagner — Wed, 07 Apr 2010 20:12:14 GMT

Hi Wynne,

many thanks for your answer regarding improve international!

katja

Re: Cert AVP

Rob Reid — Wed, 07 Apr 2010 18:20:40 GMT

[quote user="Hannah Wynne Richards"]Rob Reid I've registered with Middlesex for the A and B (SA ) modules-I'm at the moment finding it difficult to fit in the time for all the reflective essays-Areas of Learning. I could do one on the problems of referring and then being disappointed with the quality of service, the problem would be to avoid a libel action !!!!!!!!!![/quote]

I have recently submitted my essay on the problems of referring, I thought it made for quite a good topic and really got me analysing how I make my referral decisions instead of 'going on instinct.' I got around the libel action bit by not naming any names!!!

Re: Cert AVP

Hannah Wynne Richards — Wed, 07 Apr 2010 16:51:09 GMT

Rob Reid I've registered with Middlesex for the A and B (SA ) modules-I'm at the moment finding it difficult to fit in the time for all the reflective essays-Areas of Learning. I could do one on the problems of referring and then being disappointed with the quality of service, the problem would be to avoid a libel action !!!!!!!!!!

Vicky I agree with you that the shortage of future ophthalmologists is worrying-especially as not all veterinary schools have ophthalmologists, or for that matter, cardiologists on the staff.

Katja. I'm also doing a B(Equine ) module with Improve I've passed the exam, but have had to resubmit the case history, so am waiting to find out if the second attempt is good enough. I can really recomend this, very well taught. Assesment is by both exam and case history, which I prefer - possibly showing my age, as I'm the generation who were used to all-important end exams

Wynne

Re: Cert AVP

Bradley Viner — Wed, 07 Apr 2010 15:24:36 GMT

"I do believe that anything worth having needs to be worked for and I do take serious issue with the suggestions of some of your associates that merely growing old while in practice imparts a special ability/superiority/status that in itself should be recognised."

I agree wholeheartedly. I believe anyone tackling one of the new certs will have to work hard. Very hard. I've already said that personally I believe that the new CertAVP will be "larger" than the old Certs. And experience does not equate to learning. Most definitely.I'd be interested to know where you got the impression that any of us thought that was the case.

My query about assessing surgical ability was a serious one. Case reports do not in themselves evidence it, neither do written papers. Cadaver surgery might, especially if you habitually operate on dead patients. It's a real issue and the Universities involved in assessing the new surgical modules have given it serious thought and have developed some sophisticated means of attempting to get to grip with the issue, but there is a long way to go.

Finally, neither I nor to my knowledge other members of what was the SPVS Masters/Doctorate group (that has now evolved into Vet Learning) have been vociferously critical of the old certs. They acheived a great deal. It is a matter of report from the RCVS that the pass rate for practiioners was very low, and we have already discussed whether that is a good or a bad thing. I say again that as a group we were primarily interested in getting a GP Certificate recognised by the RCVS, and this happened to co-incide with changes that the RCVS had decided, in principle, to make. I personally do think that the CertAVP has many advantages over the old Cert, but it is also far from perfect, and I hope with time they will also evolve into something better still.

Glad to see you are settling back into some spirited abuse Malcolm, I thought things were getting far too cosy

Re: Cert AVP

Malcolm Ness — Wed, 07 Apr 2010 09:40:08 GMT

[quote user="Bradley Viner"]There are others (and I suspect Malcolm would be one) who would see a high pass rate as a sign of weakness. [/quote]

Unsubstantiated b******s.

A problem with politicians is that they agrue against what they want to be said, not what was actually the case.

I do believe that anything worth having needs to be worked for and I do take serious issue with the suggestions of some of your associates that merely growing old while in practice imparts a special ability/superiority/status that in itself should be recognised.

In answer to your earlier question about the old certs - it was almost all clinical material. To exclude the case reports is evidence that you don't understand the process - the case reports provided evidence of how candidates were making clinical decisions, how they were accessing and using information and they provided evidence of the candidate's level of technical skill and expertise. The written exam was/is framed to concentrate on clinically relevant skill and evaluation and avoids the pointless memory test/intellectual showing-off type questions. Trouble is these questions require the judgement of an experienced expert clinician to mark - these questions are one of the first victims of the currently (and almost certainly transiently) fashionable world of QAA. A large part (80% plus) of the oral part of the exam was case based with live patient exams, cadaver surgery and radiographic cases a part of every exam that I ever was involved in.

Surely the SPVS maasters group know all this - certainly some of them have been very vociferous in their criticism of the old certs - are you now implying that this criticism was based on an almost profound ignorance of the subject???

Re: Cert AVP

Rob Reid — Wed, 07 Apr 2010 09:37:40 GMT

[quote user="Vikki Halliday"]Ethically ideallistic Bradley! But also explains why your modular Cert AVP courses are more expensive than most?[/quote]

Is that comparing the Middlesex Uni course to the other CertAVP suppliers or other modular certificates in general? I am registered with the RVC (with online support) and the cost is less when compared to another modular course supllied by a CPD company I did a few years ago.

When I sat down and worked it out - if I did the modular cert over 2 or 3 years it actually worked out as rather good value for money compared to if I just went on day courses over that period.

Re: Cert AVP

Bradley Viner — Wed, 07 Apr 2010 00:51:16 GMT

Absolutely. Providing quality peer support and supervision, with formative as well as summative assessment is costly. But we are committed to supporting students properly. We have already had students that have started on other courses transferring to us because they have realised (the hard way) just how important that sort of support is. To many of us that have been through the learning set experience, the learning and friendship we have gained from those working with us have been as rewarding as the qualification itself.