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In 1863, a group of veterinary surgeons gathered togetherto discuss the formation of a society for veterinary medi-

cine, which then became the United StatesVeterinaryMedical Association (USVMA) with the motto Non NobisSolum (Not for us alone). By 1889, this society was renamedthe AmericanVeterinary Medical Association (AVMA), anorganization that now boasts over 81,500 members andoversees 21 specialty organizations.The AVMA’s mission is“to improve animal and human health and advance the vet-erinary medical profession.”With advancements in veteri-nary healthcare and the burgeoning role that specialtyproviders now play, the general veterinarian’s role hasevolved from one who makes a diagnosis and providesnearly all types of treatment to a primary doctor who offersroutine wellness exams, vaccinations, and ensures that theirpatient receives the very best care available.

In many instances primary care veterinariansare able to provide high quality medical careto sick animals, but there are situations wherethe level of care may be best delivered by aspecialist. So how does a primary veterinariandecide when to make a referral?

According to Dr. Dina Raichel of Windan’Sea in La Jolla,CA, the veterinarian should refer the dog to a specialistwhen the patient requires advanced testing and diagnostics,such as endoscopy or an ultrasound exam. Financially, it isimpractical for a small veterinary facility to buy the neces-sary equipment for advanced testing, some of which costs$600,000 and upwards. In some cases, an advanced proce-dure like orthopedic surgery or the removal of a large massmakes it clear that a board certified surgeon needs to beconsulted. But, when a dog becomes ill, the issue of whomakes the diagnosis or treats the patient is not alwaysapparent. Some clients want to take a conservative approachand elect minimal diagnostic testing and/or just empiricaltreatment because they are afraid of incurring exhorbitantexpenses.What these clients do not realize, however, is thatin some instances a specialist can actually save them moneywith a direct approach and a defined treatment plan.

According to Dr. Kirk Feinberg of Governor Animal Clinicin San Diego, the generalist’s attitude towards specialists haschanged in veterinary medicine over the years. Since theearly 1980s, there have been significant advancements inspecialty areas along with an increase in board certified spe-cialists and organizations. Dr. Feinberg explains that twoself-oriented fears can inhibit a general practitioner frommaking a referral.The generalist’s first concern is the loss ofthe patient to another hospital: If I send my client to them,will they take over the client and take over the dog’s care? Thesecond hesitation comes from the veterinarian’s own inse-curity: Am I admitting to the client that I can’t solve the problem

and thus look bad in their eyes? As generalists like Feinbergand others now claim, such egocentric apprehensionsshould take a back seat to what is best for the pet.

Ideally, general practitioners approach everymedical problem with the same question,“How do I provide my patient with the verybest healthcare that is available?” Sometimes,the gold standard of veterinary medicine goesbeyond the general practitionerʼs training ortheir available facilities.

What separates the veterinary general practi-tioner from the specialist, aside from extratraining, is the high volume of cases that thespecialist sees that are limited to a specificarea.

AsVeterinary Specialty Hospital of San Diego Director andinternal medicine specialist Dr. Keith Richter says,“Youcannot keep up with all of the literature in veterinary med-icine. It is just impossible. Specialists are lucky just to keepup in their specialty.” Indeed, the specialist provides arefined knowledge of the latest information and technolog-ical advances in the field. Ideally, every veterinarian, fromspecialist to generalist, depends upon a variety of informa-tion in order to determine how to treat each patient. Moreand more veterinarians have embraced the language andmethods of evidence-based veterinary medicine to evaluateand treat their patients, a development that has establishedan essential standard for evaluating different types of infor-mation, from personal anecdote to double-blind, controlledexperiments.

As physician Sharon Straus and colleagues understand it,evidence-based medicine is “the integration of the bestresearch evidence with our clinical expertise and ourpatients’ unique values and circumstances.” On the researchside, veterinary clinical trials and journal findings oftendepend on a small sample size that can be considered statis-tically insignificant (six or twelve dogs as opposed to thou-sands). On the clinical side, dependency on a veterinary“cookbook” – a textbook that consists of treatment direc-tives – risks overlooking the immediate patient’s presenta-tion. While the language of evidence-based medicine is stillrelatively new to veterinary medicine (it was first introducedto human medicine in Canada by David Sackett in 1980,but did not start to appear regularly in discussions until the1990s), most veterinary schools now emphasize its practicebecause it provides a common vernacular to compare infor-mation and cases.

Evidence-based medicine outlines the steps for rationaldecision-making in which the veterinarian weighs researchand the established facts alongside of clinical experience in

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SPECIALIST’S ROLEin Veterinary Healthcare

by Debra Channick, PhD

The

This Portuguese Water Dog sufferedhair loss from chemotherapy.

All photos © Dr. Craig Griffin

19The COURIER September/October 201118The COURIER September/October 2011

For example, early in his career, Dr. Richter (an internist)was trained in endoscopy by observing procedures inhuman patients and then practicing on cadavers in order todevelop techniques for scoping dogs, which continue to beused by internists today.As part of her training to become aradiologist, Dr. Mohammadian of CaliforniaVeteterinarySpecialists Hospital took classes with the physician radiationoncology residents at Duke and Chapel Hill. In addition,she participated in joint research projects with the radiationoncology departments at NCSU and Duke. Similarly,oncologist Dr. Greg Ogilvie, also at CaliforniaVeterinarySpecialists Hospital, worked with the pediatric oncologyteam at the Dana Farber Cancer Institute, the adult cancerteam at Tufts New England, and was a member of andworked with various oncologists at the University ofColorado Cancer Center. In fact, he continues his work inhuman medicine as part of the University of CaliforniaCancer Center in the Department of Radiation Oncology.Indeed, post-residency collaborative and educational oppor-tunities are abundant for motivated private practice special-ists. Oncologist Dr. Brenda Phillips ofVeterinary SpecialtyHospital of San Diego has had the opportunity to collabo-rate with San Diego area biotech companies to help developnovel treatments for veterinary cancer patients and hasreceived mentorship from members of the Fred HutchisonCancer Research Center in Seattle to develop the firstbone marrow transplant program for canine lymphomapatients in San Diego.

Diagnostic Benefits

Since establishing a diagnosis can be a frustrating andexpensive experience, it is important to understand how aspecialist can help before running up a large bill at the gen-eralist’s office. Otherwise, a client may find that they paytwice, the generalist and the specialist, before they get ananswer.

A major benefit of getting a specialistʼs opin-ion is their extensive clinical experience,which can lead to an expedient diagnosis.

Internal medicine issues like Inflammatory Bowel Diseaseor Addison’s disease can be difficult to diagnose.While ageneral practitioner may only treat an Addisonian dog everyyear or two, an internist may see up to five such cases on amonthly basis. Dr. Richter explains that he sets aside anhour for his initial consultation. He admits,“My examwould cost more, but the client would get a more focuseddiagnostic plan on the first visit and may not require multi-ple visits.”

Some clinical findings require both objective and subjectiveinterpretation, like the diagnosis of a heart murmur, done

by auscultation of the heart (listening to the heartbeat witha stethescope) and interpretation of an echocardiogram(cardiac ultrasound).As cardiologist Dr.William Herndonof CaliforniaVeterinary Specialists Hospital explains it, thediagnosis of a heart murmur is not only subjective but sub-tle. Thus, it is ideal to have someone who has spent extratime training in cardiovascular disorders and interpretingechocardiograms.

By contrast, a general veterinarian rarely has the opportuni-ty to learn and to practice how to interpret an echocardio-gram in veterinary school. Similarly, internal medicine resi-dents perform a variety of ultrasound exams and developskills in the use of the endoscope, while veterinary studentsgenerally do not have such experience.According to Dr.Lenore Mohammadian,“the radiologist provides state-of-the-art imaging and interpretation.A radiologist does notfunction alone but as part of a veterinary team (patient,client, veterinarian, veterinary radiologist). . .A trained radi-ologist supplements and enhances the ability to diagnose acase.”

In the case of oncology, a general practitioner often makesa preliminary diagnosis of cancer.According to oncologistDr. Phillips,“the actual diagnostic procedures are not alwaystechnically challenging.” Sometimes, the difficulty, Phillipsexplains, is deciding which diagnostics to perform follow-ing the initial evaluation. She says,“[The general practitioner]will test trying to answer a question, such as the severity orsubtype of the disease, but may not choose the ideal proce-dure. For example, they may submit a sample for PCR (aDNA based test) when they should have submitted for flowcytometry (a whole cell based test). Therefore, it is ideal ifthey utilize their relationship with a specialist to determinethe optimal diagnostics for a suspected or confirmed case ofcancer.” Dr. Jean Spengel in San Diego, CA, recalls a clientwho took her advice and consulted with an oncologistdespite limited funds after her dog was diagnosed with lungcancer.Although the client declined treatment because ofthe cost and the bad prognosis, Spengel explains,“she feltlike she had gotten the best information available and thatthe money was well spent.”

Unlike human medicine, which keeps dermatology andallergy separate, the veterinary dermatologist’s focus on skinissues is inseparable from the treatment of allergies.As Dr.Craig Griffin of the Animal Dermatology Clinic in SanDiego explains,“dogs’ skin issues are often caused by aller-gies.” Even though a general veterinarian can run a bloodtest for allergies, the results can be controversial and incon-clusive. A veterinary dermatologist is trained to test andinterpret allergy tests to provide not only the best diagnosis,but the best personalized treatment plan as well.

order to determine the best treatment plan for the patient.For the generalist with multiple partners, the practice ofevidence-based medicine can include what is commonlyreferred to as “hallway medicine,” a discussion of a difficultcase with the other staff veterinarians. In a specialty hospital,“hallway medicine” includes access to experts in otherareas, a significant advantage in a complicated case thatcontains multiple organ involvement.

Every owner expects that their generalist knows their ownlimitations and will tell the owner when the dog should bereferred. Dr. Raichel urges her clients to get a second opin-ion when the dog’s condition has either not improved overa period of time (and the comfort level of how long towait varies) or deteriorates.As Dr. Feinberg says,“Thesedays if you don’t have a good relationship with a specialtyhospital or don’t feel comfortable referring, you can actuallyget yourself into more problems because you may have putyourself in a position of trying to solve a problem that isover your head.” Generalists like Drs. Feinberg and Raichelboth insist that a second set of trained eyes can never hurtand, in most cases, helps. Ideally, the general practitioneralerts the specialist about a case and prepares the client’sexpectations, including the potential costs.

If a primary care veterinarian hesitates to refer a client,then it is critical to understand the reason why.The ownershould feel comfortable enough to discuss whether or notthe issue will resolve over time or if they need to go some-where else.

Some clients hesitate to ask for a referral forfear of offending their primary veterinarian. AsSan Diego small animal surgeon Dr. DanielFrankel remarks, “The emphasis of the com-munication with the generalist should be yourconcern for your pet and its health and not anattack on the generalist. The specialist shouldnot replace your generalist, but be an exten-sion of their services.” The owner shouldnever be afraid of getting a second opinion,even if the primary veterinarian does not offerthe referral.

Dr. Richter outlines the difference between what a gener-alist and a specialist does in what he describes as a mutuallyrespectful relationship. He declares:“There is no vet whosends us a client . . . where we are going to make themlook bad; that is not what we do.We support them (thevet) . . . and they do things that I can’t do.They can look atthe whole patient and I can only look at the internal issues. . . It is erroneously thought that specialists are better; weare just interested and highly trained in our specialty.”

What is Specialty Training?

Most graduates of veterinary school go on to practice clini-cal medicine in private practice. But, a small fraction ofgraduates apply and are accepted for competitive, one yearAMVA approved internships at veterinary hospitals aroundthe country where they have the opportunity to study withspecialists in a variety of fields such as oncology, cardiology,small animal surgery, dermatology, neurology and radiology.An internship provides an incredible opportunity to see alarge number of diverse cases in just one year under theguidance of experienced veterinary specialists in differentfields. Such an opportunity supplements the academiclearning of veterinary school and, at the same time, providespractical experience under the direction of specialists indifferent fields. Indeed, it strengthens the qualifications ofthe generalist.According to Dr. Richter,“interns are misun-derstood in our profession . . . they are the cream of thecrop . . . approximately 10% of veterinary students go on todo internships.” The competition for internships is fierce.For example, at theVeterinary Specialty Hospital of SanDiego, they have about 200 applicants for seven positions.The intern’s responsibilities vary depending on the veteri-nary hospital. Nevertheless, they are regarded as professionalstudents and doctors who actively participate in patient carewith a veterinary specialist who oversees all clinical decisions,tests, and treatments.They also attend specialty lectures atthe veterinary hospital and undergo regular assessmentsadministered by their mentors. By the program’s conclu-sion, some interns elect to go into private, general practicewhile others apply for residencies to pursue advancedknowledge and clinical training in a particular specialty.

Veterinary residents are internship-trained veterinarianswho choose to specialize, electing to study a particular areafor an additional two to four years.They are motivated by apassion to learn and have often been inspired by theexpertise of strong mentors and teachers. Each specialty isaffiliated with a veterinary specialty college that awardsDiplomate status to those who fulfill its requirements andexaminations.Together, the specialty group forms a looseconsortium of colleges housed and authorized by theAmericanVeterinary Medical Assoociation (AVMA), theumbrella organization.At this time, the AVMA recognizes21 specialties, which range from internal medicine and itssubspecialties (cardiology, neurology, oncology, etc.), to radi-ology, and emergency and critical care. Most specialtiesrequire at least two to three years of training beyond theinternship, but the requirements vary. Many areas like der-matology require a publication in a peer reviewed journalor, in the case of oncology, participation in a clinical study.

Since veterinary and human medicine often share com-monalities, many residents also study with human specialists.

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cortisone, but don’t factor into the approach [significantcomplications like]: the potential rupture of the anteriorcruciate ligament, bladder stones, urinary tract infections,weakened ligaments, and decreased muscle strength, amongmany other things.” Dr. Griffin explains that some generalpractitioners follow the “cookbook” route for the treatmentof allergies.The blood test and treatment set come from anallergy company with a standard protocol. If the treatmentis unsuccessful, the veterinarian will simply say that it didnot work. Dr. Griffin says,“probably 70% of my cases don’tjust stay on my standard protocol. I always have to adjustfor the pet, which is the art of using the treatment.”

As owners who endeavor to build a team of veterinaryexperts to ensure that our dogs receive excellent medicalcare, it is imperative to communicate comfortably withboth the specialist and the primary care veterinarian.As Dr.Patricia Ungar, owner of KensingtonVeterinary Hospital inSan Diego declares,“This is not an ego issue. It’s about get-ting the pet the care it needs, and the owner feeling com-fortable.” For Dr. Ungar, a primary care veterinarian with aspecial interest in holistic medicine, her integrativeapproach does not preclude her from teaming up with vet-erinary specialists to care for her patients. Similarly, veteri-nary oncologists and other specialists refer patients to Dr.Ungar because of her expert knowledge of holistic medicine.

What if I don’t live near a specialty hospital?

Since not every type of specialist is available in every city,there are alternative ways to seek assistance or to do a con-sultation, by phone or on the internet. In oncology, manyclients travel long-distances for an initial consultation andthen return to the primary care veterinarian, who willwork closely with the oncologist. However, not every caserequires an actual visit to a specialist. For example, Dr.Mahommadian explains,“many veterinarians will submitradiographs to a radiologist off site for interpretation.Withmany clinics now having digital radiology, a radiologist livinghalf way around the world can still be a part of the veterinarycare team for any hospital.” In addition,TheVeterinaryInformation Network (VIN) provides general veterinarianswith access to specialists in every field, along with a search-able database for articles and conference proceedings.

All veterinarians, specialists and generalists, are required toattend continuing education conferences and seminars inorder to keep their licenses current. In addition to hostingvarious conferences, specialty organizations also facilitateinternet discussion lists. Only veterinary specialists,Diplomates of the specialty colleges, participate on suchlists, which allow members to pose questions regarding dif-ficult cases and to share new, unpublished research.Thus, ifa list-member sees a challenging case and is uncertain ofthe diagnosis or treatment, the list-serve makes it possible todiscuss the case and find out if one of the hundreds ofother specialists has had a similar experience.

Regardless of your dog’s age or condition, it is important toknow where the nearest emergency hospital is located. Donot wait until a life-threatening emergency occurs or itcould be too late.When visiting the emergency hospital,find out who is on staff. Is there an emergency and criticalcare specialist? A specialty only recently awarded fullDiplomate status by the AVMA (1996), emergency andcritical care emphasizes the management of life-threateningcases with multiple, simultaneous medical issues along withtechniques like mechanical ventilation.

The founders of the USVMA took up the motto NonNobis Solum (Not for us alone) incredibly (and ironically)during the American Civil War.The image, the centaur,represented the inextricable bond between man and beast.Today, we embrace our beloved pets as family memberswho are entitled to benefit from the excellent healthcarethat is now available to them.We, too, can say that special-ized care is not for us alone.

We are fortunate to be able to draw upon theexpertise of both veterinary general practi-tioners and specialists working as a team inorder to ensure the best care for our dogs.

Treatment Benefits

Some clients look to the veterinary specialist for a diagno-sis, but then return to their primary veterinarian for treat-ment. In some cases, this plan makes sense. Dr. Richterexplains that he does not need to recheck an addisoniandog if the disease is under control and the dog is respond-ing to the proper medication.The primary veterinarian willoften run the bloodwork and send copies to Richter tokeep him informed. However, there are some instanceswhen the management of a case goes beyond the primaryveterinarian’s expertise. If a dog continues to suffer fromgastrointestinal issues, it may be necessary to determine arational plan under the guidance of an expert.As Dr.Griffin asserts,

“Veterinary medicine is not just about gettingan answer, but how you are going to managethe case.” Ideally, the primary veterinarianconfers with the specialist to determine whowill be able to best care for the dog.

Some clients prefer to let their primary veteri-narian treat their dog with chemotherapybecause they hope to save money, assumingthat they administer the same drugs as theoncologist. But, what an emotional client canoverlook when weighing the options is thatoncologists have the expertise and experi-ence to deal with complications and to deter-mine whether the complications are due to thedisease, the drugs, or other issues.

Indeed, oncology is a specialty that is as much an art as ascience because every dog responds differently to treatment.If a general practitioner consults an oncology handbookand simply follows the protocol, they may not have theexperience and knowledge to make changes based on thepatient’s response. Moreover, administering chemotherapyproperly is essential; most oncologists insist on a triple-check system to ensure that the proper dose is alwaysadministered. Dose alterations, calculation errors, and misin-terpretation of bloodwork are some of the risks of an inex-perienced doctor and staff overseeing chemotherapy.

While it is ideal to receive chemotherapy and radiationfrom a veterinary oncologist, it is also important to recog-nize the value of the extra supportive care they supplywhen their patients suffer from side-effects. Some oncolo-gists, like Dr. Phillips and Dr. Ogilvie, treat side-effects pro-phylactically, arming their clients with a variety of medicinesto mitigate the side-effects of the drugs and to maintain ahigh quality of life. If an inexperienced veterinarian isunaware of side-effects, they can miss something that is life-

threatening. For example, when a dog’s white blood cellcount is lowered after receiving doxorubicin, some oncolo-gists will provide the client with a hormone that stimulateswhite blood cell production.As Philips explains,“somefamilies sit home with a sick dog because they expect itfrom chemotherapy . . . we have so many things that wecan do to make them feel better! . . . It is not okay to letthem ride it out when we have means at out disposal tomake them feel better quickly.” Knowing when and whichantibiotic to give a chemotherapy patient can lead to arapid turnaround from what could have been a fataldecline.

Many primary care veterinarians maintain a special interestin skin issues and endeavour to stay abreast of the latestdevelopments in the field. Since dermatology issues oftenaffect the dog’s quality of life, it is important not just totreat for flare ups, but to figure out the best way to preventthem and manage the patient longterm. Some veterinariansoffer a quick-fix, an injection of cortisone, which Dr.Griffin refers to as the “roller coaster approach.” While thecortisone may make the dog feel better for 8-10 weeks, thedog will necessarily have to return for another round oftests and treatment.The downside of the quick-fix, in addi-tion to the financial cost of repeated trips to the veterinarianwhile the dog suffers, is the physical side-effects of the“solution.”As Dr. Griffin explains,“A lot of people like

The Specialist’s Role continued from page 19

This Portuguese Water Dog sufferedhair loss from chemotherapy.