From VPN+

“We must provide an outlet for the creative faculties…And it is this challenge which is recognized by every graduate who turns away from practice, disillusioned by his or her inability to find satisfaction in a situation where…the expectations of training are dashed by the reality of practice. Somehow, we must change the system lest the process of education leads to an increasing number of square pegs looking for a home in a world of round holes…

“We must seek to elevate the status of the practitioner, not only that his position is elevated in the eyes of the academic but, more importantly, in the minds of practitioners themselves. Too often we hear that a practitioner cannot be expected to teach or to research. This is the philosophy of despair.”¹

~Peter Rossdale¹

If I’m being honest, the first couple years of veterinary school were a bit tedious. I was a career-change student, about 10 years older than most of my classmates. I had behind me years of struggling to find a career that was meaningful and challenging, yet also economically viable. In that context, being back in school wasn’t such a bad thing. And unlike a lot of my classmates, I hadn’t always dreamed of being a vet, so I didn’t experience the shock of achieving a lifelong dream only to find it was, like reality so often turns out to be, imperfect. However, hours and hours spent memorizing facts, many of which I suspected I would never need again (and I was right!), wasn’t exactly thrilling. I did ok, but I didn’t stand out until I got to clinics.

When I started my clinic rotations, everything came to life for me. The process of clinical reasoning, of collecting and sifting through the information available to find the salient patterns, and then matching that to the tools I had to help my patients, was fascinating and satisfying. Doing medicine was enormously better than learning about it! I may not have been the smartest or most talented in my class, but I turned out to be pretty good at the clinical aspects of veterinary medicine, and my teachers noticed.

One day, an internal medicine resident came up to me while I was studying in a hospital hallway. She wanted to tell me she and some of the other residents and faculty members running the rotation had been talking about me. They had concluded I absolutely had to do a residency because, in her words, “You’re too smart for general practice.”

Of course, my first reaction was an ego-driven flood of dopamine and self-satisfaction. I appreciated the complement, and it reinforced my suspicion I was actually pretty good at this stuff. Alas ,when I had some time to think a bit more about the remark, I started to take a darker view of it.

I haven’t found a definitive source of data, but using numbers from the American Veterinary Medical Association (AVMA) and the Bureau of Labor Statistics, it seems about 20 percent of veterinarians are board-certified specialists. That number was surely lower when I graduated 20 years ago! In this context, one view of the resident’s compliment could be specialty practice is for the best and brightest, and the rest of us have to settle for the less intellectually challenging life of primary care medicine. Being a GP, in this frame, is a consolation prize or a fallback position for the majority of us who don’t make the cut.

By temperament I’m certainly a nerd, and I likely would have pursued a specialty certification (probably in emergency and critical care) and an academic career if that had been possible. However, at the time I graduated, I was 35 years old, I had a six-month-old daughter and a spouse who had indulged my search for a career long enough. I also had $160,000 in loan debt (a pittance by today’s standards, of course, but easily in the top three percent of vet school debt back then). Internship and residency weren’t realistic, and it was time to get a job.

GP life begins

So, did I settle for a lifetime of routine and drudgery? Nothing but vaccines, spays and neuters, and anal glands until I retired? Or maybe, at best, the challenge of entrepreneurship and running a small business? Am I the old guy who hasn’t added a new procedure, drug, or piece of equipment to his toolbox since most new grads were born and doesn’t see why the way we did things in the “good old days” needs to change? Well, not exactly…

I have found many ways to sustain my engagement and enthusiasm with medicine, to challenge myself and grow, both professionally and personally, in my work. Most importantly, I have maintained a commitment to high-quality, evidence-based medicine (EBM), and I have been able to help my patients and clients, and even contribute to the growth of the veterinary profession—all as a lowly GP. So how did I do that?

To start with, when my first practice didn’t meet my expectations for quality of care or opportunities to learn, I started doing relief work at local emergency hospitals to take on more challenging cases. In the absence of a mentor willing and able to teach me, I looked for every opportunity to learn the hard way. It was pretty scary being on alone at night right out of vet school. It wasn’t how I would have chosen to learn, but such a sink-or-swim approach seemed all that was available to vets not destined for internships and residencies in those days.

Once I had a few years in practice, I managed to talk my way into an exceptional hospital, which I have long considered a model of what is possible in general practice. We have been an independent 24/7 practice with up to 30 veterinarians, almost all GPs, and many extremely talented technicians, including some with VTS certification. Management always supported individual veterinarians in pursuing their interests, which allowed me to offer abdominal ultrasound and echocardiography, endoscopy, chemotherapy, and a high-level of surgical and medical care to my patients.

While working in this rich environment, I have constantly striven to “up my game.” I got involved in the Evidence-based Veterinary Medicine Association (EBVMA), helping to lead this organization made up largely of academic veterinarians. I have published and spoken on evidence-based medicine and promoted it to primary practice clinicians around the world.

I have also been lucky enough to have the opportunity to teach veterinary students in practice. Many come to clinics with a wealth of facts crammed into their heads and little idea how to organize and use them effectively to help patients. As much detailed content knowledge as they get from each specialist they train with, many students get very little process knowledge.

Clinical reasoning skills, the ability to take all the knowledge they have ingested over the years, and both organize and use it effectively to make decisions in real time across a broad set of medical domains and patient populations, is something few veterinary students I see have had the chance to think deeply about or practice. This is one area in which the general practitioner is preeminent; the pragmatic evaluation of available information and application of available resources to solve clinical problems within the inevitable constraints of time and money. The broader the range of problems you have to solve and the more limited your tools for solving them, the more efficiently and creatively you have to think!

I have also continued my formal education, completing a master’s degree in epidemiology. Even at this stage (don’t you dare say “venerable!”) of my life and career, I am seizing opportunities to learn and grow. I have shifted to part-time clinical practice so I can take on a role in canine aging biology research. I still do spays and neuters, vaccines ,and anal glands, but that is hardly a fair summary of my career as a GP.

Of course, my path isn’t the right or the only way to make life in primary care practice meaningful and challenging. It is just one example of many possible paths. Yet, I think it belies the notion academic veterinarians all too often inculcate in their students that being a GP is a dead end, a second class of veterinary career.

I still run into this view from time to time. When doing an advanced echocardiography training course, I was chastised for even thinking I should be able to offer this service by the other students (all internists). A few specialists have been offended when I questioned their recommendations, even when I could present clear research evidence to support my concerns, and their position relied entirely on their clinical experience and authority as diplomates. And the medicine resident who encouraged me to pursue specialization so many years ago was not the last to suggest, with the best intentions, my knowledge and abilities were somehow inconsistent with my role as a GP. I doubt I am the only primary care veterinarian to have such experiences.

How to accurately envision general practice

So, how should we think about the role of GP? How should we see ourselves fitting into the profession, and how should students and academics learn to understand our role? What strengths and limitations characterize the general practice role, and how do these complement the academic and other veterinary roles? All of these are deep and hard questions with no simple answers, but I will offer a few thoughts.

Given primary care practice is where the vast majority of patient care happens, our profession has an ethical responsibility to prepare GPs for providing high-quality, evidence-based care. Many of the students I teach and the new graduates I mentor seem to come out of the veterinary educational system with the idea they should handle only minor problems and refer anything challenging.

The definition of what is appropriate for GPs to manage seems to shrink yearly. It’s not just the shock I still sometimes see when I talk about performing an echo or an endoscopy in primary practice. I have had new graduates who felt it was inappropriate to interpret a radiograph or diagnose a mast cell tumor on cytology without specialist input. The message they often seem to get from their teachers (nearly always academic specialists) is that if a specialist can do something then a GP shouldn’t do it.

Of course, this extreme view is not consistent with practical and economic reality. The obvious problem of insufficient specialty capacity and the inability of many pet owners to afford the cost of specialty care is an obvious flaw in this model. However, I believe there are other flaws to this view that are more grave.

One is that such “dumbing down” of general practice to routine wellness care and management of only minor health problems diminishes the quality of care patients receive. It creates a self-fulfilling prophecy. If we teach veterinary students that talent, intelligence, and ambition can only be satisfied in specialty practice, then people with those attributes will eschew general practice. If we don’t teach GPs that they should be practicing high-quality, EBVM because only specialists can do that, then it will become true.

Another problem with primary practitioners gradually ceding diagnosis and treatment of serious problems to specialists should be abundantly clear from even a casual glance at the human healthcare system. The hyperspecialization of human medicine has led to absurdities.

I once started explaining the nature and management of a cranial cruciate ligament rupture to a client when he stopped me with a chuckle. He was an orthopedic surgeon. After four years of undergraduate education, four years of medical school, an internship, and more than one residency, his entire career consisted of six procedures on the human knee. A brilliant, and arguably overeducated man, had been reduced to a highly paid, very specialized carpenter.

Is this the model we wish veterinary medicine to follow? Laying aside the economic realities that would impede full adoption of the hyperspecialization, is this even a model we should aspire to? I would argue it is not, yet that is the direction we would head in if the lessons many of my students and new graduates take away from their training were implemented.

Advantages GPs possess

The strengths of the primary care practitioner are many. We have a holistic view of the patient throughout the lifecycle that is usually unavailable to the specialist. While our knowledge base is inevitably shallower than those in specialty practice, it is broader, allowing us to integrate multiple medical conditions, husbandry, and other owner variables, individual temperament, life stage, and many other factors into the management of specific healthcare problems. I would argue this approach typically allows for better overall patient care, especially when cases are complex with multiple concurrent morbidities.

GPs are also consummate problem solvers, accustomed to making do with limited information and resources. If this ability is not only honed by experience, but strengthened by the application of evidence-based medicine techniques and training in clinical reasoning, it becomes a powerful tool. Specialists are undoubtedly knowledgeable, talented, and creative thinkers, but depth of expertise comes at a price; the loss of a broad perspective and a tendency to follow familiar patterns within a domain even if elements of the context outside of that domain might suggest a different approach.

Finally, there is the obvious issue of accessibility and affordability I have already mentioned. Too many companion animals already go without care because their owners cannot afford it.² Increasing the reliance on specialists without a fundamental shift in the economic model of veterinary medicine will simply make care less available to more patients.

Apart from the benefits to patients and clients in supporting high-quality care in general practice, encouraging GPs to value themselves and their work, and to stretch themselves professionally, is important to maintaining a talented and satisfied veterinary workforce. We all know our profession is struggling right now, with vets bearing the stacked burdens of high workloads, huge debt, and the many physical and emotional challenges of the job. Constraining people to smaller, and smaller boxes, as GPs or as specialists, is just creating more round holes for Dr. Rossdale’s square pegs. Channeling the most ambitious and talented students into specialty practice or academia, and denying those who do go into general practice the opportunity to fully engage their intellect and creativity in their work can only exacerbate the problems our profession is facing with burnout and job dissatisfaction.

How, then, can we encourage all of our students and new veterinarians to maximize their potential, provide the best possible care for our patients, and avoid the pitfalls of hyperspecialization that bedevil our colleagues in human medicine? As I have already implied, I think evidence-based medicine is a key part of the answer!

Teaching all veterinarians, regardless of their eventual area of practice, to practice EBM would be a good start. While some effort to do this is already part of the curriculum, I cannot say most of the students or new graduates I see have really absorbed the core concepts of critical thinking and reasoning that underlie EBM. We are still emphasizing memorization and regurgitation of facts over rational, effective reasoning strategies.

My students are better able to search the literature and use electronic information tools than my generation, but they don’t often seem to understand what these tools are for. They still seem to rely primarily on authority and the dicta of their mentors for guidance rather than using the information they have learned to support critical reasoning. When I question the rationale for a particular treatment choice, all too often the response is still, “That’s what Dr. X said to do.”

Teaching veterinarians to think critically and independently, and to rely on critical appraisal of controlled evidence when possible, can only improve the quality of clinical reasoning and patient care. It also has the advantages of strengthening one’s confidence in one’s recommendations and practices, and reducing the tendency to defer to academics or specialists, which drives a lot of the relinquishing of cases and problems that could appropriately be retained in the general practice setting.

EBM also helps to delineate the role of generalist and specialists. In areas where there is strong evidence to guide diagnosis, prognosis, and management, there is less need for the deep and narrow knowledge and experience of the specialist. Conversely, when a problem is uncommon or not well understood, and there is little reliable evidence concerning it, a specialist’s strengths become critical.

As an example, the vast majority of the heart disease cases I see in practice are myxomatous mitral valve disease (MMVD). This is a relatively well-understood condition with clear diagnostic and staging criteria, and strong consensus guidelines available to inform treatment. I use echocardiography to support my management of MMVD cases. In my career, I have done a few over 1,000 echocardiograms, and about 85 percent of these have been MMVD cases. There is no reason why the greater expertise and experience of a cardiologist should be necessary to diagnose, stage, and manage this condition in most patients with typical presentations.

My use of this tool fits well into the role and competency of the general practitioner. And the skills I have developed evaluating MMVD patients have helped me utilize the tool in other ways that improve patient care. I don’t need to call in a cardiologist to identify a right atrial mass prior to subjecting a patient with hemangiosarcoma to a splenectomy. I can identify and manage pericardial effusion without the delay of waiting for a specialist or transferring the case. All of these are reasonable and natural elements to primary care.

On the other hand, there are absolutely cardiac cases that fall outside my competency that I should, and do, refer. I don’t ultrasound young animals with murmurs because many will have uncommon congenital anomalies I am not qualified to identify or manage. And whenever there is a case that does not fit well into a clear and evidence-based diagnostic pattern, or when I find something I have not seen before, I don’t charge the client for my scan and I call in a specialist who is better equipped to evaluate and handle the case.

Maximizing the potential of GPs does not mean disdaining specialists or not referring cases when appropriate. It means delineating the domains of the two rationally rather than by tradition or by organ system. EBM is a useful way to support primary care practitioners in developing their knowledge and skills, maintaining their job satisfaction, and providing high-quality care while also utilizing specialty and academic services when these are necessary and will benefit the patient.

Of course, even I recognize EBM can’t solve all of our problems. The lessons my students and new graduates are absorbing about their place in the profession are predominantly cultural lessons, expectations of the whole community as envisioned by a small subset of the profession. Academics don’t complain to their students about the failings and misjudgments of GPs because they are mean people. They do so because they see a skewed sample of cases that end up at the university. The most unusual, most difficult problems and those that have not been solved by primary care practitioners are most of the cases that make it to the teaching hospitals. All the cases we manage successfully, often within strict constraints of money and other resources, are invisible to those who teach students how to view the general practice role.

As a profession, we have to think deeply about how we understand the categories of general practitioner, specialist, and academic. If we want to avoid the excessive costs and harm to patient care that have come from hyperspecialization in human medicine, and if we want to provide satisfying and challenging careers for all new veterinarians, we need to avoid the trap of seeing academia and specialty practice as the brass ring and primary care as a consolation prize.

References

1. Rossdale PD. Combining research with veterinary practice. Can Vet J. 1978;19(12):327. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1789444/. Accessed July 29, 2021.
2. Stull JW, Shelby JA, Bonnett BN, et al. Barriers and next steps to providing a spectrum of effective health care to companion animals. J Am Vet Med Assoc. 2018;253(11):1386-1389. doi:10.2460/javma.253.11.1386