When a case is sent by a referring veterinarian (RDVM) to a specialist or emergency practice, the unwritten standard is to start where the RDVM left off and base the next step on what is needed by the referral documentation. This is professionalism. To request that the RDVMs should send a pair of flat-plate X-rays and a blood chemistry/CBC, as applicable as a baseline, is also professionalism. To repeat the blood and X-rays sent by the referral RDVM, when they are current and of appropriate quality, while there has been no change in the patient, is a matter of bio-ethics:

 The specialist/emergency practitioner wants their own...

 The specialist/emergency practice has a policy of...

 The specialist/emergency practice does not trust the RDVM...

 The specialist/emergency practice has a "social contract" with the RDVM

 Enough time has passed, and the conditions have changed. Sequential lab or imaging is needed to assess the patient...

It is obvious that some of the above are the "wrong reason", or are they? Some emergency practices have shareholders, and the shareholders expect special care. When Dr. Mike Sweeney had shareholders on the west side of Denver, his shareholders could send the q.i.d. treatment patients to the emergency practice, and Mike would provide treatment as directed, without office call or emergency fees. That was considered a "professional courtesy" to the people investing in his practice, and was seldom abused by the RDVM, also considered professionalism.

In some shareholder emergency practices, however, the desire for high rate of returns has caused the dollars, not the medicine, to drive the decisions. This "desire for personal wealth", when uncontrolled by the board, causes many central specialty practices or emergency practices to be: understaffed, under-equipped, and underpaid. We describe it as "not only milking out the cow every day" but also "wanting hands full of hamburger from the same cow." That is not usually considered professionalism in action, it is a poor business practice, and that "drive" often puts the specific on-duty providers in a bio-ethical dilemma.

In some specialty practices, the specialists take home "big bucks" and treat the staff as expendable by underpaying the staff, gouging the referrals, and "bad-mouthing" the RDVMs. This is not a bio-ethical issue, and while some may say it reflects on professionalism, it actually reflects on their characters.

It is not the scientific nor the technical which make successful veterinarians, it is their leadership and life skills which are the defining success factors. - Workshop for Veterinary College Administrators, Educators, and Practice Management Consultants National Commission on Veterinary Economic Issues

In our profession, we have finally realized that life skills and character must be taught in veterinary school, but have concurrently realized they are not. Practice leaders now know that life skills and character values must be developed within the new graduates they hire, before they can be a success. Studies have shown that while veterinary applicants usually have excessive drive and determination, the culture/family where they were raised did not add adequate values and/or life-skill character to the decision-making process.

Choices

We support one emergency practice, which raised the bar in the entire veterinary community. The veterinarian there wanted the discharges to return to the RDVM directly for re-bonding and follow-up. So she sent every animal out, every morning, still on IV fluids. It was less than a year, when she started to see RDVMs send animals to her emergency practice already on fluids. It took about three years for virtually every practice to become proponents of IV TKO transport (IV To Keep Open), a standard in emergency trauma and transport in human medicine.

Inversely, we had an emergency practice where the lead doctor wanted to follow the cases he'd seen during the dark hours. So, in some cases, he did not discharge or send a morning RDVM report. In other cases, he scheduled the patient back to the emergency practice for a recheck or continued therapy. This again is character and professionalism, not bio-ethics.

What bothers me at this point in time are the tendencies toward over-treatment of RDVM referrals. When an animal is referred for overnight "observation", and the condition does not change, why does the practice demand laboratory screens are run and do intensive imaging?

What scares me is now there is an attorney roaming the practices of southern California, presenting his perfectly healthy dog, verified by a specialist, as having a "history of limping." His objective is to find "inappropriate" diagnostics and inappropriate "recommendations", to solicit legal training engagements of the practice staff:

 Some emergency practices wanted to do a major work-up.

 Some emergency practices provided pain management and referred the attorney back to the RDVM.

 Some emergency practices want a full-night admission to evaluate the dog.

 A few had even "diagnosed" ACL and wanted to do "emergency" surgery.

In another scenario, this same attorney accessed both the general practice and emergency practice, presenting his perfectly healthy dog, verified by a specialist, as having a "history of gastric upset", and he stated he had pet insurance:

 A few practices did just a consult with palpation, no diagnostics, and told him to return if something else happened.

 Some practices quoted a fee $50 in excess of the superior VPI plan.

 Some practices empirically treated and told him to come back in three days.

 Some practices did abdominal X-rays, found nothing, and then treated symptomatically, with a recheck in three days.

 Some practices did abdominal X-rays, found nothing, did a blood chemistry panel with CBC, found nothing, then treated symptomatically, with a three-day recheck.

 Some emergency practices did abdominal X-rays, found nothing, and then wanted to do additional diagnostic studies overnight.

 Some emergency practices did abdominal X-rays, then did additional diagnostic studies, got all negatives, so they stated they needed to do "emergency abdominal surgery".

This appears to be the basis of a bio-ethical issue to many practices: getting caught! If the standards of care are not established, and fear of "getting caught" is the motivation, then we have a character issue, as well as a bio-ethical issue. Not referring the non-acute cases back to the RDVM is a professional issue, while the perception of "over-treatment" is a bio-ethical issue to discuss eye-to-eye between the RDVM and specialist/emergency practice medical director.

Reality

In unpublished studies by Dr. Hiram Kitchen, before his death, he divided the fourth year VTH class into three cohort groups, and then developed "clients" from the senior class of thespians on campus. He trained the thespians to be stewards of an aging cocker spaniel with newly diagnosed cancer, and provided them the core values of a "B" type pet owner. The "B" type considers pets are members of the family, but not necessarily people. Only a third of the people, who consider their pet "family", give them "people status". All this is described in greater detail in Chapter 2, Building The Successful Veterinary Practice: Programs & Procedures.

The three cohort groups were given the same laboratory and radiology data, but provided different core values and different standards of care, which varied the "expected" treatment and prognosis:

 One was pro-euthanasia. It was too expensive to treat and would not extend the dog's life more than a year.

 Another group was the pro-chemotherapy regiment, using cutting-edge therapy.

 The third was pro-surgery, "a chance to cut is a chance to cure", with extensive biopsy and histopathology support.

Enter the "thespian cocker owners", one at a time, into the consultation room, and the video tape was running:

 The "owner" made the decision ninety-five percent of the time according to the veterinary cohort group "expectation scenario".

 The "doctor" was often data based, and some even put feeling into their delivery, while others did not. It did not change the prognosis or outcome.

It was statistically valid to state, the doctor's assessment swayed the core values of the owner as steward of the animal, and life-or-death decisions were made based on the provider's statements. This was bio-ethics in action, to the clarity of all.

We do have a choice as a profession, and it will be facing us soon. If we do not monitor and improve ourselves, including conducting a peer review for bio-ethics and professionalism at every level, RDVM or specialist, then some politician will legislate the requirements to us. I pray I never see that day.