Getting A Second Opinion
- Feb 1, 2000
Your horse comes up lame. You call your veterinarian and have him or her come out and examine the animal. Your practitioner prescribes a treatment protocol that is carried out. The horse improves somewhat, but a nagging lameness remains. You call and ask your veterinarian to make another visit to your farm. The veterinarian arrives, examines the horse again, and tells you to continue with the prescribed therapy--that the horse just needs more time to mend.
At this juncture, you begin to wonder if something else should--or could--be done to solve the problem. You want a second opinion.
But, now you face a dilemma. You like your veterinarian and want him or her to continue servicing your horses' routine medical needs. How do you go about getting another opinion without offending? Is there a proper procedure? Are you at risk of offending your veterinarian to the point where he or she will no longer want you as a client?
There can be, has been, and perhaps always will be, the potential for emotional conflict and jealousies among practitioners when a second opinion is sought, particularly if that opinion is sought from a veterinarian who is looked upon as a competitor. While personality problems involving a second opinion likely exist, they are relatively few and far between in today's high-tech approach to veterinary medicine, says Gary Norwood, DVM, former president of the American Association of Equine Practitioners (AAEP), who is involved in a multi-veterinarian practice in Metairie, La.
In most cases, Norwood said, the primary veterinarian likely will be the one to suggest seeking a second opinion or referral if a particularly troublesome medical problem arises and/or continues. "Most veterinarians do not want to go beyond the scope of their own expertise," he said. "They will try to do what is best for the horse and for their client."
Economics often is involved in the decision-making process when referral is involved, said Norwood. While modern veterinary science has produced highly sophisticated tools, they often are very expensive and not every veterinarian can afford them.
He listed ultrasound as a basic example. It has become a commonly used tool in many practices, and its use is included in veterinary school curriculums, but not every veterinarian has one. Thus, it would be likely that if ultrasound were called for in a diagnostic or treatment approach, the veterinarian without one would refer the horse to a colleague that had
Still another example is the gastroscope that enables a veterinarian to examine a horse's stomach for the presence of gastric ulcers. It is an invaluable tool, but it is expensive and most, at the moment, are in the hands of universities and specialty practices.
Thus, it would be logical to assume that when a veterinarian encounters a patient which has demonstrated symptoms of ulcers, the horse would be referred to a veterinary clinic or university that had a gastroscope.
What also happens in many areas, said Norwood, is that individual veterinarians will develop their own particular fields of expertise and, as such, take on the role of referral veterinarian. One might become an expert in dealing with teeth, another with lameness, another with throat surgery, another with eye problems, another with reproduction...the list goes on. When that happens, he said, fellow practitioners will seek that individual's help in dealing with specific problems. In essence, it is a pooling of capabilities, something that is taken for granted at multi-veterinarian clinics and at universities.
There also are many instances, Norwood said, where it is not practical for a clinic or veterinarian to do all things. He cited the clinic with which he is affiliated as an example. In the past, he said, the clinic did its own surgery work. Then, he said, it was decided that this didn't make good sense when a university with specialists on the staff was only 100 miles away. Today, the clinic's major surgeries are referred elsewhere.
There also are instances where referral is necessary because the horse needs round-the-clock care or monitoring. This might not be possible in many practices and clinics, he said, but would be feasible at a university where there is more staff, plus students, available. Referring such a horse, he said, is the only practical approach to take.
While veterinarians have become more sophisticated in their education and expertise and have more treatment tools and protocols at their disposal than in years past, there also has been a change toward more knowledge and sophistication in the trainer ranks, particularly at racetracks and performance
stables, Norwood believes.
The oldtime race or performance trainer, he said, was apt to utilize the services of a veterinarian he trusted and would stick with that person through thick and thin and never seek outside help. Trainers of that ilk still exist, and many are highly successful with that approach, he said. However, a number of others use multiple veterinarians who are specialists in respective areas.
If the modern-day racehorse trainer is concerned about EIPH (exercise-induced pulmonary hemorrhage) in one of his charges, for example, he likely would call in a veterinarian who is perceived as more knowledgeable and proficient than most in that area to perform an endoscopic examination. However, if a lameness problem is involved, he likely would call in someone else--someone who has a reputation for being an expert in the field of lameness. The list goes on.
Under normal circumstances, Norwood said, the trainer's primary veterinarian would not take offense at such an approach. It is routine in today's modern horse world.
However, he did admit that it can be frustrating to the regular veterinarian if his or her diagnoses routinely are questioned by the client, and the initial examination is followed in quick order by a number of outside practitioners who also are asked to make a diagnosis.
In some instances, Norwood said, a client's impatience might fuel the desire to seek a second opinion or referral. "The horse is treated and almost immediately the client is wondering why it isn't well yet."
Robert Lewis, DVM, the 1999 AAEP president who is involved with a large equine practice in Elgin, Texas, is frequently on the receiving end of referrals and people seeking a second opinion. A number of his referrals are horses in need of orthopedic surgery.
The referral and second opinion seekers are varied, he said. Some will come armed with information provided by their primary veterinarian, while others will provide nothing other than their own interpretation of what ails the horse.
"Through the years," he said, "I've become accustomed to dealing with them all."
In some cases, he said, the clients do not want the person who is giving the second opinion to have any background knowledge. "They want the referral veterinarian to start fresh in arriving at a diagnosis."
The problem with that approach, he said, is that it can be costly for the owner. Lewis uses X rays as an example. If a lameness problem is involved and the primary veterinarian took radiographs of the affected limb, it would be pointless for the referral veterinarian to repeat the process. The most economical and feasible approach, he said, would be to have the radiographs accompany the horse.
Specialized services and treatment protocols are expensive at best, without repeating what already has been done, Lewis said. "You can burn up somebody's pocketbook in a hurry."
There also can be communication problems between the referral veterinarian and the client if the primary veterinarian is not involved, Lewis said. The client might be attempting to pass on the information received from the primary veterinarian, but frequently will not have the medical background to understand it to the point where it can be articulated accurately to the referral practitioner.
Under those circumstances, Lewis said, the referral veterinarian might be missing some significant information that is known by the primary examiner, but which the client is unable to express.
One of the reasons clients do not want to involve the primary veterinarian when they are seeking a second opinion, Lewis said, is fear of hurting that practitioner's feelings.
While that might occur, he acknowledged, most veterinarians are primarily concerned with the horse's welfare and will do all they can to cooperate with the referral practitioner. Lewis has been on both sides with many horses having been referred to him and with some whose owners sought to go elsewhere. When the latter is the case, he said, it is the practice of the clinic with which he is involved to make available to the referral clinic or university all of the information that has been garnered.
There are cases, Lewis said, where the primary veterinarian might suggest referring the case, but the client doesn't want to use the veterinarian or clinic suggested. When that occurs, he said, the client often will strike out on his or her own in an effort to find another referral veterinarian or clinic.
A hypothetical case, he said, could involve Dr. X as the primary veterinarian. Dr. X suggests that the horse be referred to Dr. Y. However, the client has had friends tell him that they have utilized the services of Dr. Y and weren't satisfied. This could lead the client to seek another referral veterinarian, which he or she might do without further consultation with the primary veterinarian because the client wants to avoid conflict over the primary veterinarian's recommendation.
What should be uppermost in everyone's mind, client and veterinarian alike, he indicated, is the welfare of the horse.
"We often are dealing with a highly charged athlete," he said, "that often is asked to perform with injuries that would sideline a football or soccer player."
Although veterinary medicine and modern techniques are highly sophisticated, he indicated, not every patient can be cured, even though the horse is referred to the greatest of experts in the field.
Simply referring a horse or seeking a second opinion is not a guarantee of success.
Norwood used the great racehorse Cigar as an example in discussing how even the best of techniques and the expertise of many top people in the field can fail. Cigar was a champion on the track, but when he was retired to stud, it was found that he was infertile. He was referred from one stallion reproductive expert to another, but, in the end, all had to conclude that the horse was sterile for life.
Compounding the problem, said Lewis, is the fact that equine patients can't tell the veterinarian what ails them. "I do a lot of orthopedic surgery," he said, "and it is sort of like doing work with pediatrics because my patients can't tell me what's wrong."
What advice would Lewis offer to someone seeking a second opinion? For starters, he said, be honest with the primary veterinarian. "Look each other in the eye" and tell him or her that you want a second opinion. Then ask the veterinarian's advice concerning finding the proper referral practitioner, university, or clinic. Finally, ask the primary veterinarian's cooperation in providing all information that has been accumulated in his or her involvement with the horse.
That approach, he said, not only will save the client money, but will give the referral veterinarian a better chance at understanding the problem and determining the correct steps to take in solving it.
The AAEP has addressed the issue in part in its "Ethics and Professional Guidelines" under the sub-title "Guidelines for Referral Cases." The guidelines are reprinted here in the hope that they might help the horse owner better understand the veterinary community's approach to referrals as well as the value of involving the primary veterinarian when the client is seeking a second opinion or referral.
First the AAEP provides these definitions:
Referring Veterinarian--The veterinarian who was at the time of referral, in charge of the patient.
Consultation--A deliberation between two or more veterinarians concerning the diagnosis of a disease and the management of the case.
Referral--The transfer of responsibility of diagnosis and treatment from the referring veterinarian to the receiving veterinarian.
The guidelines then deal with the method of referral:
Communication should be by letter, telephone, or direct contact between veterinarians. The most appropriate method of communication should be determined by the veterinarians involved.
The referring veterinarian should provide the receiving veterinarian with all the appropriate information pertinent to the case before or at the time of the receiving veterinarian's first contact with the patient or the client.
When the referred patient has been examined and definite findings have been made, the referring veterinarian should be promptly informed of those findings. Information provided should include diagnosis, proposed treatment, and other recommendations.
Immediately upon discharge of the patient, the referring veterinarian should receive a detailed and complete report, preferably written, and be advised as to continuing care of the patient or termination of the case.
The receiving veterinarian should advise and encourage the client to contact the attending veterinarian for the continuing care of the patient.
Each veterinarian involved will collect his or her own fee from the client.
In today's high-tech equine medical world, the referring veterinarian today might be tomorrow's receiving or referral veterinarian.
The AAEP best sums up what should be and, in most cases, is, the approach taken by veterinarians in the field. It is the first paragraph of the "Standards of Profession" in the "Ethics and Professional Guidelines:
"Professional ethics embodies the behaviors of honesty, integrity, and kindness while obeying rules and regulations set forth with mutual respect and preservation of dignity in interpersonal relationships. The conduct should be in a manner that will enhance worthiness of the profession."
Then comes the clincher.
"The ethical practice of medicine are those remedies and treatments which have, as their short-term or long-term goal, the health and welfare of the horse."
If one's veterinarian lives up to these principles, it behooves the client to do likewise. This means dealing with the veterinarian honestly and openly, even when seeking a second opinion.
About the Author
Les Sellnow is a free-lance writer based near Riverton, Wyo. He specializes in articles on equine research, and operates a ranch where he raises horses and livestock. He has authored several fiction and non-fiction books, including Understanding Equine Lameness and Understanding The Young Horse, published by Eclipse Press and available at www.exclusivelyequine.com or by calling 800/582-5604.
POLL: Colic Surgery