Straight to the specialist?

Vets are often still on the ‘Little House on the Prairie’ model

If you’ve been reading my column faithfully, you already know I broke my big toe a few weeks ago. (I like to remind people I did it falling off my bike, an admirably active undertaking.) It happened on the weekend, so I went to the emergency room after the accident, where they diagnosed the fracture. Then I went home, put my feet up, and waited for the swelling to subside. But day after day my whole foot remained swollen and painful. Now, I’m not particularly stoic, but I figured it was probably a sprain, so I stuck it out for two weeks. Finally I called my doctor. “He’s just going to refer you to the orthopedists,” the receptionist said. “Why not go straight to them? Here’s the number.” So that’s what I did. Straight to the specialists. Do not pass Go. Do not collect $200.

When I was a kid, we had a “family doctor.” Think Dr. Baker on Little House on the Prairie. Our doc made house calls when we were sick … that’s how old I am. Nowadays doctors specializing in family medicine, general pediatrics, or general internal medicine provide people with what is called “primary care.” This is defined by the American Academy of Family Physicians as care provided by physicians specifically trained for and skilled in “comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis.” Your primary care doctor knows an amazing amount of stuff, but when you break your toe, he still may send you to the orthopedist.

Veterinarians, well, we’re still on Little House on the Prairie much of the time. On the other hand, just as the practice of human medicine has become exponentially more sophisticated, moving more and more toward specialization, so has veterinary medicine. The dilemma is this. Few people question when their primary care physician sends them to a cardiologist when they are having chest pain (even when it means a trip off-Island.) If you have cancer, you go to an oncologist. If you have glaucoma, you go to an ophthalmologist. But if you have a dog or a cat, you just go to your veterinarian, and expect optimum care. Today we have the ability to refer Rover and Fluffy to veterinary dentists, surgeons, ophthalmologists, dermatologists, oncologists, cardiologists, and so on. In fact, we are ethically obligated to at least offer such referrals whenever a pet’s problems go beyond the basics, but most pet owners hesitate when we suggest taking an animal on such a journey.

For normal people (i.e., those living on the mainland), consulting a veterinary specialist is less daunting than for Islanders. For us, such an appointment likely means a whole day of lost work, a hard-to-get ferry reservation, maybe even an overnight stay in Falmouth. It is a stress on a sick animal as well as on the owners. “I don’t think Fluffy can handle the car ride,” I often hear from the owners of seriously ill or elderly pets. Sometimes it’s the humans who can’t manage the traveling. There are a surprising number of Vineyard folk who don’t feel comfortable driving off-Island, especially if it involves a foray into the city. That often leaves us in a bit of a conundrum. We can’t force a client to go to a specialist, but when they don’t go, we are often faced with having to treat a patient without a definitive diagnosis, without optimum equipment, facilities, or staff, and without the focused training, expertise, or experience to provide state-of-the-art care.

In some ways, this need for figuring out creative solutions is often what has drawn an individual to go into veterinary medicine in the first place. We tend to be a pretty independent bunch, and the challenge of figuring out how to wing it in such circumstances is just part of what we do. But times are changing, and so are the expectations of pet owners. Every veterinarian has his or her own approach to handling referrals. Some eschew sending clients to specialists, focusing on providing the most comprehensive services they can right at their practice. This makes life easier for clients in many ways, but can also do them a disservice if they end up missing out on receiving state-of-the-art care. Other veterinarians refer very frequently, insuring access to optimum care, but then not always being able or willing to provide well for those clients who choose not to go to a specialist. Most of us live somewhere in the middle, offering referral, but doing our best to be that old-time doc and make do when needed.

Which brings us to the crux of the matter. The decision about whether or not to seek the care of a specialist is really up to you, the pet owner. You have to weigh the pros and cons. Face the medical facts, have realistic expectations, then take responsibility for the decision. Please try not to blame your “primary care” veterinarian for not being an ophthalmologist, surgeon, oncologist, dermatologist, and cardiologist, all rolled into one. We know it can be expensive, time-consuming, and emotionally draining when your pet has a serious illness. We can’t change the cost of a specialist, or the ferry schedule. We can’t change that a pet has cardiomyopathy, lymphoma, or a broken leg. What we can do is try our best to help you navigate your options.

The orthopedist said I needed a CT scan. That took several days to arrange, and several days more to get the results, but I didn’t mind. I was just grateful we don’t have to go off-Island for these anymore, that I could get it done right here at our hospital. While I waited for results, I pondered all the limping dogs I have seen these past 30 years. And the fact that none of them ever had a CT scan of a paw.