Are there any things that you (dr.k) absolutely insist a specialist for ?  just curious :)

LC: I consider specialists an excellent "tool." This is how my boyfriend (a vet surgeon) urged me to consider his services when I first met him by phone six or seven years ago. I've never had cause to think of specialists differently ever since. 

The idea is this (and, so you know) it's different than how it works in human medicine): General practitioners see the big picture. But their experience on X procedure or Y disease is limited--or their hospital is limited by having no 24-hour care. We them employ the surgeon/internist/cardiologist either to perform specific services or "take over" a case's management, given our limitations. 

The generalist is the specialists' client in a way. Having a great relationship with a specialist means the specialist calls the GP and talks over the case. The specialist does not presume to undertake all manner of approaches and procedures the regular vet is uncomfortable with (on behalf of his/her patient) or is otherwise opposed to. 

For my part, I refer whenever I know a client is willing to seek out the best, whenever I'm totally uncomfortable with my degree of knowledge/skill or my equipment/hospital's limitations. 

That's why many of us refer to cardiologists or ophthalmologists (equipment and very specialized knowledge) but keep surgeries/internal medicine in house whenever we can. We tend to feel more comfortable with the latter, which is why so many of us don't refer, though I always like to offer the surgeon/internist because I know they're better--and I trust that my clients are like me...they want the best when they can afford it.

OT, but Miami Veterinary Specialists started an internship program this year and they'll be continuing it in spite of the economy--they have three internists, three surgeons, two dermatologists an an oncologist/radiation oncologist. I don't know if they're in a matching pool or how it works anymore but I would definitely write you a recommendation!

Awesome, I'll definitely keep them in mind! I would love to go to Florida for the exotics and the close proximity to Dr. Xie and the Chi Institute, but I'm also Minnesota born-and-raised... I'm not exactly built for heat and humidity! I think my ideal would be the pacific northwest, but I guess you end up whenever the match puts you. We'll see what happens!

I think the individual GP skills is another thing to consider too. Not all GPs are equal. And exactly where do vets like ABVP feline certified vets fit in....Certainly not an internist, but from my own experience on IBD/pancreatitis/other cat lists, their skills with GI disease seem to be pretty equal to others I know that go to internist when their cats have a similar degree of illness. My ABVP feline certified cat-only vet actually charges as a specialist.

There are specific areas where they have used specialists. They have a board certified radiologists that travels to the clinic abdominal ultrasounds, a cardiologist and internal medicine specialist to perform echocardiograms (heart ultrasounds), and a boarded opthamologist they work with on difficult cases. My vet also recommended that I go to a boarded surgeon for my cats exploratory surgery. But so far, their management of both my IBD/pancreatitis cats long-term care has been excellent and I don't see some of the miscommunications I see from some who have to work with both a GP and internist to manage their cats long-term care.

A great topic! And I think you are right on! IMO, if you tell the client about your limited experience honestly, explain the pitfalls you know about and/or experienced---it is really an informed decision. If you are completely "uncomfortable", say so, and refer.

When my Pearl needed her spinal disk surgery, a couple in the Mid-west had successful experience with their GP doing their dog's surgery for a serious "fraction" of what I was facing. They offered home accomadations, transport, etc. and even with the flight and dog (under the seat) OR driving, would still have been far cheaper. I respectfully declined in the event, I needed follow-up for complications.

Another good long-time Canadian friend offered to have certain surgeries (spay)& routine workups at her Vet clinic, also at a considerable savings. I don't see any legal reason not to, but again, have not taken advantage of the offer. (which with multiple pets, would add up $$$$)

And really what I wanted to comment; it is my belief that GP's have certain areas that they enjoyed/excelled in training/education, that probably meet a specialist's expertise, be it internal, eyes, complicated bone surgeries, whatever.

Barbara A. Albright/NH

Somyr - 

I had a very similar experience with my veterinary ophthalmologist - after he did my dog's cataract surgery there were some (eye) complications.  Even after scheduled follow up visits to the ophthalmologist, it turned out my GP found the complications and had me ask him about them.  He didn't seem very pleased about that and tried to brush them off.  Shortly after, my dog lost the sight in one eye. So now I always have my GP do eye checks first. 

I've taken my megacolon cat to an internal medicine specialist just shy of a year ago.

I wanted a second opinion on treatment options and to find out a rough estimate on surgery should it become necessary. While I cannot afford the surgery ($3,000) I was happy to discover they had a different treatment method with medication.

It's been almost a year since we started that treatment regimen and my cat has not had to have one single enema in that time. Before that he was having to get enemas about every 3-4 weeks.

So while I confirmed that I could not afford the surgery I did find out there were other treatment options, sans surgery, and that was worth every high priced penny I paid them for.

Sometimes just being able to do a consult with a specialist is worth the money. Neither I nor my cat regret having made that appointment.

Interesting post - just this week I opted to go straight to the specialist after a few moments with my general vet - in the past I probably would of had the general vet do the ultrasound, x-ray and exam then evaluated if I needed to go to the specialist who usually does it all again but I thought heck might as well save the money at the general vet and just do it all at the specialist which actually in this case did save me alot - in fact I am in the last year leaning towards just go to the specialist - if its a specialist that doesn't re-do all the prelim work then I split it up but for those "specialists" who insist on doing all the prelim I am just going...In a nut shell the economy isn't stopping me from going to the specialist I am just trying to figure out how to still go but still save money ?  LOL 

Right now I have a dog with a chronic swollen paw, I am considering not going to my general but instead going straight to derm specialist..since I have already in the past spoken to my general about it, why should  I go there and pay another office visit, more general tx stuff when I could save that money and go straight to the specialist ? 

Yes, "PJBoosinger" said above the specialist fees are higher (sometimes) but I have found for specific especially chronic things the results are well worth it....and in some situations it saves you money, quicker more efficient treatment for your pet, better results, etc....

I think there are probably certain things going straight to a specialist is in fact better for your pet and can indeed conserve funds ?  Only one I can think of off the top of my head is Cardio - if I ever suspect cardio issues straight to the cardiologist. 

Are there any things that you (dr.k) absolutely insist a specialist for ?  just curious :)

Hope the surgery went well !

I'm not entirely persuaded that specialists fees should be as high as they are; sometimes looks like value billing.  While I have no objection to that in a good economy, I wonder if they've considered taking a "we're in this mess together" attitude and cutting their prices (discounts shown right on the bill).  Just IMO that the higher a person's professional capacity, the higher the ethical obligation as well.  (Besides, would be good PR for them to boot.)

"I’ve found an interesting lesion on your limping dog’s knee. I think it’s probably a normal variation but I want a radiologist’s second opinion to be sure."

Dr. K: Your honesty never seizes to amaze me! I only wish that my dog's internist has said that to me "I want a radiologist's second opinion to be sure"--my companion's life would have been spared! I don't know if it was arrogance or ignorance, but it cost my companion to die an agonizing death because of this internist's US misinterpretation.

Asproolee’s Story

I love this post. My biggest peeve with specialists is that they are often so narrowly focused on their approaches to treatment they seem to ignore other body parts. In my experience, GPs excel at seeing the big picture, and although that might be a more stressful position for a GP because they have to know a little about a lot of things, in most cases, I find that to be more comforting than a vet who knows a lot about a just a little.

GPs don't give themselves enough credit, sometimes, and are often afraid to step on specialists' toes because they have more alphabet soup after their DVM. After several months of battling my kitty's corneal ulcer, my GP threw up her hands and said, I can't do it anymore! You have to see the specialist. OK, I thought, my GP just totally freaked out. Specialist must be super necessary.

So now we've been seeing the veterinary ophthalmologist every three or four weeks since before Christmas. Yes, he's a smarty-pants with a ACVO and ACVS; and yes he is expensive. He also doesn't do anything in his exams or treatments any differently than a GP would. In fact, he probably does less of a thorough exam than a GP does; but he's more comfortable prescribing ultra-spendy antivirals.

I half-wish my GP would have invested in a phone consult with the specialist and kept my kitty's case to herself.

Hi arriss - I had Alpine dairy goats for a little over a decade, and never had a wether that stank - smell is due to male hormones and rather revolting breeding season behavior!

With the current state of the economy . . scarcity-fear-etc,  we're engaging in  more of a "cast your fate to the wind" approach.  Trust, and surrender with developed discernment rather then believing just throwing large amounts of money at problems can solve everything.

Thank you for sharing your perspective Dr. K. We (AAHA) are in the process of conducting a follow up economic survey to the one we conducted in July. The results should be available at the end of March. I'm curious to see how the findings will relate to yours in a national setting. As soon as I get the data, I will send it your way. Thanks again.

Megan: OT, but Miami Veterinary Specialists started an internship program this year and they'll be continuing it in spite of the economy--they have three internists, three surgeons, two dermatologists an an oncologist/radiation oncologist. I don't know if they're in a matching pool or how it works anymore but I would definitely write you a recommendation!

Consider, happily or unhappily, that techs can be more expensive than interns. You're one more well-educated warm body to a specialty practice--always a plus, especially in a bad economy. Also consider that instead of hiring that new specialist they really needed before the economy tanked, some practices will make do with interns--yep, cheaper! 

My cats have better health care than I do. With three of five having special needs, I like to stick with their specialists, but I'm currently looking for a general practice vet for the routine kinds of things. I've spent way more money than most people ever would, but can't look into a recovering cat's eyes and tell her that I'm out of money so she dies. It's really a sticky wicket and one that a lot of folks are dealing with. But, yes, I'm trying to use a general practice vet for the cats for what I can, but will not give up their specialists. (But I'm lucky enough to live in the same town as a highly respected university vet teaching hospital so I have lots of really good folks working with my cats!)

Our caseload at the teaching hospital is definitely down, which is a bummer in some ways (fewer patients for students to learn from, techs are getting laid off and there is a hiring freeze, etc), but nice in others (we get to spend more time per patient, so our clinicians can let us slow students do more than they normally would). Our professors seem to be reflecting the economy in their language lately too- "You don't have to refer your bone marrow biopsies to a specialist- you can take them yourself in general practice!" etc etc.

I'm hoping to apply for an internship in 2010, but I'm getting nervous that private practice internships will be cut back as clinics are having to figure out how to stay afloat. Hopefully the economy will be recovering by then...

Thank you for being a vet that is willing to do this....and a pox on anybody who might possibly then blame you if something goes wrong because you gave it your very best efforts and knowledge, but had informed them that you were NOT a specialist.  That is how I work with my vet.  I feel very confident that he is a great vet and I adore him and his work.  And since he knows how much I love my standard poodle therapy dog if something bad comes up he refers us to a specialist.  She dove off a high creek bank last year and ended up with hind quarter paralysis.  The vet advised me that my choices were to treat with steroids and provide good nursing care and hope that it was just a pinched nerve that would heal....or to carry her 350 miles to University of Florida vet school to make sure what we were dealing with and to get the very best care.  Of course I opted for the vet school which was a wonderful but very costly experience,.  We had a very thorough examination/consult and a CAT scan (which they counseled me on as being the least expensive, but that it would not be definitive if they could not see anything...and then the big dollars MRI would be the next step if I wanted to go on to fine tune a diagnosis)  The CAT scan did not show any damages that would account for the paralysis, so with my agreement we decided to continue the steroid treatment and do the intensive home nursing care that would be required....and thank you GOD, she finally recovered and is as right as rain.  I say all this to say that I could have stayed with my vet's initial gut feelings and probably had the same outcome, but he wasn't sure and he knew how much I love this dog.  Since the  economy is pretty scary right now and I am impacted just like many others, I probably would not be able to take this route again.  Now some people might blame my vet and say he referred me unneccessarily... but he gave me the options.  Then some people might stay with the vet's treatment and possibly the dog would have more serious problem than thought and end up permanently damaged....and then they would blame the vet again.  People are so blame happy...never wanting to take responsibility for their own decisions and actions.  You HAVE to chose your vet carefully and get to know them and their motivations.  If they are a true animal lover then you will know it, and you will know that they feel the same way about their animals as you do about yours.  They will do their very best.  And sometimes the very best does not work.  If you just chose a vet based on convenience or because everybody else uses them, or because they charge the lowest prices...then you don't have a partner to make these kinds of decisions with any kind of confidence.  You should blame yourself for not taking the time and effort to find a great vet.  Then, God forbid, if a bad outcome happens...you have to blame the fact that we are all human and we never know for sure what is going to happen to us or to our pets, even with the best of care.  It is scary that the economy is tanking and affecting everyone and that you won't be able to afford specialists.  Make sure that you have a great regular vet...and then support them and  take an active part in caring for your own animals and don't leave it all up to them.  The vet didn't cause my dog to dive bomb off a high bank.....she's an active dog...that's what she does  (or USED to do....I watch her like a hawk at the creeks and rivers now and if I see a danger zone, I call her off......that's MY responsibility as a pet owner!!)

PS  Thanks Dr Patty for the previous advice on my warty poodle.  The vet checked them again and we biopsied a couple.  It's just the normal papillomas and sebacous cysts.  Thank goodness she has no coat problems and the warts don't show up and I do my own clipping and grooming so I can watch out for them.   Also, I am now the proud owner of triplet pygmy goats, all males, all different colors who will be coming home with me when they are weaned.  Please tell me that it is true that they won't be stinky if they are "wether-ized".  The breeder assures me that this is so, and says that the wethers are more docile and laid back than the does and I want to use them in nursing home visiting. (of course she has an abudance of male babies...so...was I scammed?) 

I LOVE GREAT VETS.  BLESS ALL OF YOU

We talked about your post today at work, and yes, we are seeing the same thing at the cat hospital too. Puts it more in perspective, as we are still busy...

Teri and the cats of Furrydance