3. small him. Pract. (1975) 16, 11 1-1 16.

The second-opinion case-( 3) the referring Veterinary Surgeon’s point of view

D. R . G R E E N Veterinary Surgery, Norton Way North, Letchworth, Herts.

This paper is an expression of my opinions and attitudes to the case which is ethically referred by an attending veterinary surgeon to another, whom he re- gards as a consultant. This subject has always been important and is likely to become even more so for the following reasons. We have ever-increasing scientific knowledge of obscure disease conditions; we are beginning to use very complex equipment to aid in the diagnosis of disease or to monitor its progress under treat- ment; and we are continually developing difficult and unusual surgical proce- dures. Combined with these aspects is an increasing awareness by the practising veterinary surgeon and the general public of the veterinary expertise available to their pet, and this is likely to lead to an escalating demand for referral of the diffi- cult case. This increasing demand is already showing itself and is leading to prob- lems and frustrations for the practising veterinary surgeon. This paper is based on the headings of why and when we may refer a case to a consultant, what we expect for our client and ourselves when the case is referred, and where we may find the second opinion.

The reasons for referring a client to a consultant can be divided into those cases and conditions which we are obliged to refer and those which we do so voluntarily as a matter of professional judgment. There is a broad middle ground between the two, composed mainly of those cases which are referred because of unsatisfactory progress from previous treatment or surgery.

Obligatory referral may occur under the following headings : (a) Notifiable disease, (b) Export certification, (c) Professional schemes, (d) Client request.

The first two are self-explanatory. The heading of ‘Professional schemes’ refers to the BVA/KC scheme for hereditary disease control. In these schemes clients seem happy when they are able to meet the consultant and have decisions ex- plained to them, as in the ophthalmic schemes, but where they are merely pre- sented with an anonymous verdict to be interpreted by their own veterinary sur- geon, based upon the remote examination of radiographs as in the hip dysplasia scheme, then there are many rumblings of dissatisfaction.

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The Guide to Professional Conduct states that if a client requests a second opinion upon a case undergoing treatment, then we are obliged to comply with that request. This being so, I believe we should do it with good grace and refer it to someone in whom we are confident that the client will receive good advice. The referred case often involves the attending veterinary surgeon in carrying out a treatment recommended by the consultant, and ifthis is a course of action in which the former is not likely to have faith, hope or confidence, then he cannot do his job properly. In the ideal situation the attending veterinary surgeon should be able to suggest where the second opinion can be obtained and not have to refer the case to a consultant nominated and demanded by the client. Clients may often request a second opinion for the most insignificant of reasons-the mere mention of the word ‘cortisone’ for example. I n the case where euthanasia has been advised we cannot begrudge any client the priviledge of asking for a second opinion. This obligation to seek a second opinion upon client request may explain to a consultant why he can occasionally see cases for which he feels there was no need for referral.

The broad middle ground previously mentioned is probably very largely com- posed of cases referred in anticipation of client request. The attending veterinary surgeon may have made a diagnosis and instituted therapy or performed an opera- tion and only when the case is failing to make its expected progress is referral considered. Whether the failure to progress satisfactorily is obvious only to the veterinary surgeon or also to his client, may place this in the category of obligatory or voluntary referral. In this type of referral the consultant will be seeing only the failures of the veterinary surgeon’s treatment, and will not be aware of any past successes he may have had with similar conditions. The actions of the attending veterinary surgeon in previously treating the animal have been made in good faith, and he has not acted in a careless or irresponsible manner.

I n developing the theme of voluntary referral I would like to produce some form of definition and state that we have made an appreciation that the case in question would benefit from the further help or advice of another veterinary surgeon. The Registrar has stated that if we are to refer a case to another veterinary surgeon, we must first obtain our client’s consent. This is not always as straightforward as it may seem. Many people are frightened of being caught up in a whirlpool of diagnostic procedures in medical institutes and they are also fearsome of it for their beloved pets.

The reasons why we may voluntarily refer a case as a matter of professional judgment are considered under the following headings : (a) For specific surgery or therapy, (b) For diagnosis, (c) For advice, (d) For share of responsibility.

There are those nice clear-cut cases where the attending veterinary surgeon has been able to make a diagnosis and knows that a specific form of surgery or therapy is needed, but he feels he does not have the necessary skills or facilities to see the case through. When dealing with surgical procedures it is a great advantage to take the case to the consultant oneself, to see the surgery done, and if it is appreci- ated that the necessary skills are not too difficult, then the need to continue to refer

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such cases will fall. However, there are those skilled surgical procedures which would be so infrequently performed by those of us in practice that if you bring in the maxim that surgical skill is very largely dependent upon how often it is exer- cised upon the problem and not upon the total number of times the operation has actually been performed, then there will be a continuing demand for referral of certain types of difficult surgery.

There is a large group of cases where we are less able to make a specific diagnosis and at times are only sure as to which type of consultant we would recommend the client to take the case. We realize that good therapy and a helpful prognosis are entirely dependent upon an accurate diagnosis of the case, and we feel that this can only be done by someone with a greater specialist knowledge than ourselves, and with the necessary complex equipment for diagnosis or monitoring the pro- gress of the disease. The referral of a case primarily for diagnosis is not a request for the consultant to take over entirely all subsequent handling of the case.

Where alternative lines of therapy or diagnostic techniques are possible we may refer the case to a consultant for his advice as to which course of action may be best. Again we are not asking the consultant to take over the case entirely but are requesting advice as to our future actions. Indeed i t may not only be for ourselves that we refer the case, but also to reassure the client that a course of action, such as a laparotomy, is the next most sensible step in the orderly diagnosis of the condition.

The attending veterinary surgeon may wish to refer a case to a consultant because the burden of responsibility which comes with that patient. I t may be because of the intrinsic value of the animal, the possibility of legal proceedings on behalf of a purchaser, or the excessive attachment between owner and pet, or the veterinary surgeon’s own friendly family relationship with that client. In this category of referral I think we should admit that we are asking the consultant to take over the case, and we are handing on a responsibility which we are not entirely prepared to accept.

The Guide to Professional Conduct gives only one reason why we may not refer a case to another veterinary surgeon, and this is to gain a financial advantage for ourselves by means of fee-splitting.

The matter of when a case should be referred is extremely arguable and I can only say that it should be done as soon as it is realized that further advice would be beneficial, and provided that the client is willing to accept this advice.

The subject of what we would expect for our client, his animal and ourselves from a referred case is difficult to frame logically, and I think can best be ex- pressed in the ordcr of the steps taken to arrange the second opinion, and its eventual outcome. In a perfect world we might expect an easily available and prompt consultant opinion, a firm diagnosis and a successful outcome. The phrase ‘successful outcome’ should include an early recommendation for euthanasia of the hopeless case.

Considering first the referral of a case because of client demand or in anticipa-

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tion of their request, this would generally indicate their willingness to travel to the consultant’s surgery and to pay his fee. Consultants are extremely helpful in such situations, and it is most unusual to find that the client is still dissatisfied with the opinion obtained. They are also usually willing to assume the many responsibilities of a case having financial or legal implications. Far greater problems arise in the categories of voluntary referral for treatment or diagnosis. We will probably have a client who has good faith and trust in our own abilities and it may be a great surprise to them if they are advised that a consultant opinion should be obtained, especially if this is upon the first presentation of the animal for this particular illness. Before giving their consent they would generally wish to know from whom and where i t may be obtained, and possibly how much it may cost. I t would be presumptuous of us to decide for any individual client how much inconvenience and expense he would be prepared to accept, but, in general, it is the difficulty in being absent from employment and the distance to be travelled that are greater burdens to the owner than the cost involved. In many cases no real estimate of the cost can be given since the number of diagnostic tests needed or the type ofsurgery or therapy involved may not be obvious to the referring veterinary surgeon. We would make the appointment for that client, and try to provide the consultant with a reasonable case history including aqy diagnostic data already obtained, such as radiographs or the results of laboratory tests. The client may have had to wait some considerable time before the appointment may be taken up and this may be due to the need for the animal to be left untreated so that the present medication may not give rise to a false improvement or influence the diagnostic tests which are to be carried out. I n short, having put himself to some incon- venience, the client is anxious for his pet and hopes for action. A satisfactory referral for the client and his veterinary surgeon will probably depend upon the criteria of apparent interest, prompt action and effective communication.

I t is annoying to hear from a client that the consultant did not seem to be interested in the case, or that he was so over-burdened by other worries that he was not at that time able to give proper consideration to the problem before him. The client’s unfavourable impression will be reinforced if the veterinary surgeon re- ceives a very non-committal communication from the consultant suggesting a symptomatic treatment and giving no diagnosis. If this apparent lack of interest is correct the consultant should not have agreed to see the case in the first place.

The client may come away very satisfied by the way the consultant has handled the case, and knows that he must await the results of various samples taken from the animal before a diagnosis can be made. At best he may have been given an estimate of the time which will be taken to do these tests but will become very dis- satisfied if there appears to him to be an undue delay in reporting the results of the tests. I t is his own veterinary surgeon whom he will keep pestering, and it is most embarrassing to have to try and contact the consultant in such a case and to in- duce him to act.

The greatest frustrations in the referred case arise where there is a minimum of

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communication between the referring veterinary surgeon and the consultant when the latter continues with serial examinations or treatments of the case. Referral should not imply carte blanche for the consultant to take over the case entirely. The referring veterinary surgeon is still interested in the case, would like to learn some- thing from it, and wishes to participate in its outcome. It is a ridiculous situation if a case undergoing treatment by a consultant should suddenly deteriorate at home and, because of lack of communication, the attending veterinary surgeon does not know what type of treatment has been given. If a case being treated by a consultant should critically deteriorate, then the client expects to be able to receive a further appointment in the very near future. I t is embarrassing to have to persuade a consultant or his secretary for this appointment, rather than to have it willingly given. The ideal referred opinion would be with both veterinary surgeons present, so that all the implications of diagnosis may be fully discussed. This is usually not possible and if communication is minimal, then considerable confusion, especially over symptoms may result. If the consultant feels that the signs and symptoms he is observing are contrary to those described by the referring veterinary surgeon, then surely this should be an indication for immediate communication before he com- mits himself to a diagnosis. The appearance or disappearance of symptoms are of significance in the clinica-l diagnosis of disease, and I think it very presumptive of the consultant to assume that the practising veterinary surgeon had missed certain symptoms or imagined others. Without communication the referring veterinary surgeon will have little or no idea of the increasing cost to his client; this is a subject the client does not like to raise himself with the consultant, and for which he is usually not given an opportunity. Referral of the most interesting cases are the ones fraught with the greatest dangers. They may vanish into a vacuum as far as the referring veterinary is concerned. At the worst, the end of the referral may be indicated by a large account for numerous consultations, accompanied by a post- mortem report suggesting that i t had provided the consultant with an interesting clinical study of the progressive pathology of a fatal disease. Early euthanasia of the known hopeless case is surely more appropriate. Good communication is vital and essential for all concerned if the case is to be resolved satisfactorily.

Where to obtain a second opinion, particularly in the area of obscure and diffi- cult conditions, is a continuing problem. The increasing delay over the arrange- ment of an appointment for a client must be a reflection of the increasing demand for consultant opinion. From practice we have the following avenues available to us: (a) Within a partnership, (b) The universities, (c) Commercial laboratories, (d) Private consultants.

The first choice of referral would probably be a colleague within one’s own practice. I t has the advantage of two veterinary surgeons conferring together upon one problem, and is easily available to the client. I t is a discouragement to clients to devote themselves to one particular veterinary surgeon in a practice and is an example to junior staff to bring their problem cases into the open and discuss them with a partner. However, this is not usually regarded as a consultant opinion, and

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since I have used the phrase so many times I would like to produce some form of definition. I would regard a consultant as one whose attainment of a higher degree would indicate an increased knowledge in a particular speciality, or whose posi- tion of employment in a veterinary institute would indicate a responsibility for a particular speciality, and the facilities to study it in depth.

Traditionally in practice, we have referred difficult cases needing consultant opinion to the universities, and for their part they have accepted them in the hope that they will provide good clinical material. Increasing demands for referral, and this rather haphazard method of finding clinical material for teaching purposes, is beginning to show signs of strain. I wish the universities and any other institutes offering help to the practising veterinary surgeon would publicize the type of case they will enthusiastically accept, and also those for which they feel they cannot offer help. It is embarrassing to have to persuade a consultant to take on a case rather than have him willingly accept it. The universities have the disadvantages of all large units in the problems of communication, i.e. consultants cannot be traced within a building, or secretaries may be dominant links in a chain of communication.

The advent of the excellent service provided by the commercial laboratories has probably reduced the need for referral of a client outside one’s own practice, especially where the major reason was for help with diagnostic pathology.

There are a few veterinary surgeons of consultant status in private practice. I find their handling of the referred case and their channels of communication most impressive. Their only apparent drawback appears to be that many are single- handed and not able to provide a service during periods of vacation.

The types of specialist opinion available to the practising veterinary surgeon are not representative of the time we spend in practice on certain problems. From the BSAVA Practice Survey Report we learn that a great deal of our time is taken up by skin and other related disorders, whilst orthopaedics and ophthalmology take up far less of our time. If a similar survey was made of the consultant opinions avail- able to us, I do not think it would fairly reflect these proportions. If the demand for referral of the difficult case continues to increase, I think there must also be a development of consultant opinion. I t is unreasonable to expect that this should come solely from the universities. I think it will mostly have to come from the .private sector. Whether consultant status is to be achieved through acknowledged examination or by the process, as in France, of self-nomination, must be left to our professional bodies.

Any criticisms made in this paper were intended to be constructive, rather than destructive. We are very grateful in practice for the help we have received from consultants and many of the results are a wonderful advertisement for the skills of our profession. Any failures are, fortunately, very few, and mostly result from over-demand upon the system. A case is usually referred to gain an advantage for the patient. If either the client, his veterinary surgeon or the consultant approaches the referral with the wrong attitude somebody’s pride may easily be hurt, but more importantly the patient may fail to benefit.