SPECIALISTS SPECIALISTS AND REFERRALSAND REFERRALS

Dennis M. McCurnin, DVMDennis M. McCurnin, DVMDiplomate,ACVSDiplomate,ACVS

Louisiana State UniversityLouisiana State University

SPECIALISTS SPECIALISTS AND REFERRALSAND REFERRALS

Dennis M. McCurnin, DVMDennis M. McCurnin, DVMDiplomate,ACVSDiplomate,ACVS

Louisiana State UniversityLouisiana State University

SPECIALIST:SPECIALIST: A PRACTITIONER A PRACTITIONER WHO DEVOTES PRACTICE TO A WHO DEVOTES PRACTICE TO A SPECIAL CLASS OF DISEASESSPECIAL CLASS OF DISEASES

-Dorland-Dorland

A specialist in V.M. is a A specialist in V.M. is a practitioner who has obtained practitioner who has obtained

special status through an special status through an approved course of study and approved course of study and successfully passed a series of successfully passed a series of examinations as recognized by examinations as recognized by the AVMA’s American Board the AVMA’s American Board

of Veterinary Specialties(ABVS)of Veterinary Specialties(ABVS)

SOME 36 Vet. Med. SOME 36 Vet. Med. SPECIALTY BOARDSSPECIALTY BOARDS

Some by speciesSome by species- i.e. poultry, avian, lab animal, - i.e. poultry, avian, lab animal, equine, food animal, feline, etc.equine, food animal, feline, etc.

Some by medical disciplineSome by medical discipline- i.e. dentistry, surgery, medicine, - i.e. dentistry, surgery, medicine, pathology, behavior, cl. path.pathology, behavior, cl. path.

(Assoc. of Vet. Family Practice)(Assoc. of Vet. Family Practice)

SPECIALISTS ARE REFERRED SPECIALISTS ARE REFERRED TO AS DIPLOMATES OF…TO AS DIPLOMATES OF…

THEY CAN DESIGNATE: THEY CAN DESIGNATE: DIPLOMATE, ACVIM AFTER NAMEDIPLOMATE, ACVIM AFTER NAME

Or use DACVIMOr use DACVIM

General practitioner could “limit General practitioner could “limit practice to Equine” or “limit practice to Equine” or “limit

practice to surgery” but should practice to surgery” but should not use the term “specialist” not use the term “specialist” unless boarded in a specialty unless boarded in a specialty area recognized by ABVS of area recognized by ABVS of

AVMA AVMA unless…unless…

You are You are willing to be willing to be held to the held to the

samesame practice practice standards as a standards as a

Board Board Certified Certified

Specialist!Specialist!

Human Medicine: Human Medicine: 95% MDs are specialists in 95% MDs are specialists in

one of 150 boards.one of 150 boards.

Veterinary Medicine: Veterinary Medicine: 12% DVMs in 36 areas but 12% DVMs in 36 areas but

43.5% new grads in 43.5% new grads in advanced training today.advanced training today.

NEW GRADUATESNEW GRADUATES Published AVMA data on % of Published AVMA data on % of

new grads pursuing advanced new grads pursuing advanced studiesstudies

1996: 17.9%1996: 17.9% 2001: 23.4%2001: 23.4% 2006: 32.9%2006: 32.9% 2008: 39.0%2008: 39.0% 2009: 43.5%2009: 43.5%

INCOME: SPECIALISTS vs INCOME: SPECIALISTS vs NON-SPECIALISTSNON-SPECIALISTS

Mean income P/P Specialists vs. Mean income P/P Specialists vs. Non-Specialists: $167,862 / Non-Specialists: $167,862 / $111,674$111,674

Mean income Corporate Mean income Corporate Specialists vs Non-specialists: Specialists vs Non-specialists: $140,893 / $106,681$140,893 / $106,681

JAVMA 234, 2009JAVMA 234, 2009

STEPS TO BECOME A STEPS TO BECOME A SPECIALISTSPECIALIST

1.1. Internship (1 year)Internship (1 year)

2.2. Residency (2-4 years)Residency (2-4 years)

3.3. Credentials approvedCredentials approved

4.4. Examination (oral, written, Examination (oral, written, practical)practical)

5.5. Diplomate status ( recertification )Diplomate status ( recertification )

RESIDENCY TRAININGRESIDENCY TRAINING1.1. Formal programsFormal programs

2.2. Alternative programs (priv. practice)Alternative programs (priv. practice)

If a clinician takes extra If a clinician takes extra courses and works with a courses and works with a specialist; are they then specialist; are they then

specialized?specialized?

Liability of Not ReferringLiability of Not Referring If a specialist is within a reasonable distance of the practice the GP should provide the client with a If a specialist is within a reasonable distance of the practice the GP should provide the client with a referral optionreferral option when when

managing potentially difficult cases.managing potentially difficult cases. If the GP proceeds If the GP proceeds withoutwithout offering a referral and complications develop then the client may have recourse.offering a referral and complications develop then the client may have recourse.

REFERRALS TO REFERRALS TO SPECIALISTSSPECIALISTS

11.Consultation.Consultation-Phone/e-mail-Phone/e-mail

– – What can I do? How?What can I do? How?

2.2.Case referralCase referral

– – When? What? How? Who?When? What? How? Who?

Why do practitioners refer?Why do practitioners refer?

Uncomfortable with caseUncomfortable with caseKnow clients will get better Know clients will get better

treatmenttreatmentLack skills or equipmentLack skills or equipmentLack of time Lack of time Too sick-lose money Too sick-lose money Concern about liabilityConcern about liability

Why practitioners refer…Why practitioners refer…

Good experiences with referral Good experiences with referral hospitalhospital

Know specialistKnow specialistNeed to meet client expectationsNeed to meet client expectationsCannot diagnoseCannot diagnoseCannot handle emergencyCannot handle emergency

HOW TO REFER A CASEHOW TO REFER A CASE1.1. Complete exam / Complete exam /

Talk with clientTalk with client2.2. Call for Call for

appointmentappointment3.3. Provide medical Provide medical

record/tests/x-record/tests/x-rays/ultrasoundrays/ultrasound

4.4. Provide follow-up Provide follow-up carecare

TELEMEDICINETELEMEDICINE How to refer ?How to refer ? Call or e-mail firstCall or e-mail first Send history, exam findings, clinical pathology results, ultrasound, radiology, ECG, etc. ( no VCPR )Send history, exam findings, clinical pathology results, ultrasound, radiology, ECG, etc. ( no VCPR ) Receive back a DDX, TX, recommendations for case management and follow-upReceive back a DDX, TX, recommendations for case management and follow-up Fee is passed on to clientFee is passed on to client

RESPONSIBILITIES OF RESPONSIBILITIES OF THE SPECIALISTTHE SPECIALIST

1.1. Receive case in timely mannerReceive case in timely manner

2.2. Communicate with client and Communicate with client and RDVM (establish a new VCPR)RDVM (establish a new VCPR)

3.3. Refer client back to RDVM with Refer client back to RDVM with follow-up instructions (verbal, follow-up instructions (verbal, written, e-mail, etc.)written, e-mail, etc.)

THE SPECIALIST MAY THE SPECIALIST MAY NOT PROVIDE OTHER NOT PROVIDE OTHER

“SERVICES” WHILE “SERVICES” WHILE CARING FOR THE CARING FOR THE

PATIENT PATIENT WITHOUTWITHOUT PRIOR APPROVAL FROM PRIOR APPROVAL FROM

THE RDVM.THE RDVM.

REFERRALS OF REFERRALS OF EMERGENCY CASES EMERGENCY CASES

AFTER-HOURSAFTER-HOURSResponsibility of DVM to provide Responsibility of DVM to provide

emergency serviceemergency serviceMaintain some serviceMaintain some serviceRefer all cases to emergency Refer all cases to emergency

facilityfacilityRotation scheduleRotation schedule

WHO IS RESPONSIBLE WHO IS RESPONSIBLE FOR FOLLOW-UP FOR FOLLOW-UP

COMMUNICATION?COMMUNICATION?

THE THE SPECIALIST SPECIALIST

WHO ACCEPTS WHO ACCEPTS THE CASE.THE CASE.

WHO IS RESPONSIBLE WHO IS RESPONSIBLE FOR MISTAKES MADE FOR MISTAKES MADE BEFORE REFERRAL?BEFORE REFERRAL?

RDVM, RDVM, BUTBUT IT IS IT IS HANDLED AS HANDLED AS

PROFESSIONALLY PROFESSIONALLY AS POSSIBLE.AS POSSIBLE.

AS A SPECIALIST: NEED AS A SPECIALIST: NEED TO PROTECT THE RDVM TO PROTECT THE RDVM

BUT CONTINUE TO BUT CONTINUE TO EDUCATE FOR EDUCATE FOR

PREVENTION OF THE PREVENTION OF THE SAME MISTAKES.SAME MISTAKES.

SPECIALISTS IN SPECIALISTS IN PRACTICEPRACTICE

1973: ACVS 75 total (5)1973: ACVS 75 total (5)2009: ACVS 1634 total (1250)2009: ACVS 1634 total (1250)Second opinion now commonSecond opinion now common

FUTURE CHALLENGEFUTURE CHALLENGE

Increased competition between Increased competition between Practice, University and IndustryPractice, University and Industry

Salary and benefits $100-$150k Salary and benefits $100-$150k ($70k new grad.)($70k new grad.)

Secondary vs. tertiary careSecondary vs. tertiary care

DISASTER DISASTER PREPAREDNESS FOR PREPAREDNESS FOR

YOUR PRACTICEYOUR PRACTICE

Outline provided by Dr. Greg Outline provided by Dr. Greg Rich, Metairie, LA.Rich, Metairie, LA.

1. PRACTICE PREPARATION1. PRACTICE PREPARATION

Records- Medical / BoardingRecords- Medical / Boarding ( must have all client contact infor.)( must have all client contact infor.)Computer Computer BackupBackup (Zip, CD.,USB) (Zip, CD.,USB)Animal Transport ( A/C ) 24-72 hrs.Animal Transport ( A/C ) 24-72 hrs.Evacuation site ( safe & secure )Evacuation site ( safe & secure )Retail items & valuable papersRetail items & valuable papers ( move to safe height to keep out of water. ( move to safe height to keep out of water.

Fire proof safes are NOT water tight )Fire proof safes are NOT water tight )

PRACTICE PREPARTIONPRACTICE PREPARTION

Financial / Personnel / Insurance / Financial / Personnel / Insurance / Payroll records in water proof bags Payroll records in water proof bags for safe travel with you.for safe travel with you.

Copy of all practice employees Copy of all practice employees contact information to include cell contact information to include cell phones and email adressesphones and email adresses

2. Facility2. Facility

Lock and secure all windows and Lock and secure all windows and doors.doors.

Remove all art work and store in Remove all art work and store in water tight bagswater tight bags

Relocate all retail items to a safe Relocate all retail items to a safe and dry locationand dry location

3. ANIMAL PREPARATION3. ANIMAL PREPARATION

Individual transport cagesIndividual transport cagesCopies of all records w/ each Copies of all records w/ each

animalanimalFood supply for 2 weeksFood supply for 2 weeksEmergency drugs & suppliesEmergency drugs & suppliesEmergency DVM contact Emergency DVM contact

information for new siteinformation for new site

4. INSURANCE COVERAGE4. INSURANCE COVERAGE

AVMA liability ( Travel & AVMA liability ( Travel & Multiple locations)Multiple locations)

Business Insurance ( Business Business Insurance ( Business Umbrella, Contents, Business Umbrella, Contents, Business Interruption, Flood, Signage )Interruption, Flood, Signage )

INSURANCE COVERAGEINSURANCE COVERAGE

Professional DisabilityProfessional DisabilityHealth InsuranceHealth InsuranceProfessional LiabilityProfessional LiabilityEmployment liability Insur.Employment liability Insur.

protection from sexual harass.,protection from sexual harass.,

discrimination, wrongful term. discrimination, wrongful term.

5. EMERGENCY CONTACTS5. EMERGENCY CONTACTSEmergency Phone ListEmergency Phone List

Emergency Check listEmergency Check list

Questions?Questions?