Communication

Clear and legible medical records are the cornerstone of good communication among veterinarians. Veterinarians have a responsibility to write legibly or type their records. Thorough documentation in medical records encompasses all diagnostic testing, procedures performed, drug dosing information, client communications, outstanding test results, and communications between the general practitioner and specialist prior to referral. Veterinarians should fully write out words in medical records, and only commonly used and widely accepted abbreviations should be included. Medical errors should be documented in patients' records.

Although a referral form can facilitate communication of important information, it is not a substitute for a complete medical record. When referring a patient to a specialist, the referring veterinarian has a responsibility to fax, mail, or provide to the client the complete medical record, including laboratory test results, radiographs, and any other information pertinent to the patient's medical condition. Copies of laboratory test results, rather than simply interpretations of them (ie, “CBC results normal”), should be included in the medical record provided at the time of referral. Clients have an ethical and, in many cases, legal right to their animals' medical records, and these records should be voluntarily provided in a timely fashion on request. Every effort should be made by the referring veterinarian to provide this information so that it is readily available at the time of the initial referral appointment. Specialty practices should consider calling the day before to request records on any patient that is being referred and for which there is not yet referral information.

Because there may be situations when a referral is made on an emergency basis, the committee recognizes that it may not be possible to provide a complete medical record to the specialist at the time of referral. Whether this referral is made via telephone or fax, pertinent medical records should be provided as soon as practically possible. In addition, results of any laboratory tests performed by the referring veterinarian that are still pending should be forwarded as soon as they are received.

By making sure that clear and complete medical records are available at the time of the initial referral examination, referring veterinarians will facilitate the initiation of diagnostic testing and therapeutic planning and avoid potential delays that could compromise patient care or result in redundant diagnostic tests being performed. Illegible or incomplete medical records may not only delay the initiation of diagnostic testing or treatment, but may also create a potential legal liability.

Once a specialist examines a patient, the specialist has a responsibility to communicate the status of that patient to the referring veterinarian. Notification the same day the animal is first examined at the referral hospital should be the goal for all specialists. This notification may involve a telephone call, e-mail, or fax that alerts the referring veterinarian to the referral or to the animal's admission to the referral hospital. Some referral hospitals may elect to fax the initial history, physical examination findings, and treatment plan to the referring veterinarian. Periodic updates on the status of a patient admitted to the referral hospital should be provided on a regular basis to the referring veterinarian. The frequency and detail of these updates will vary on a case-by-case basis, but the referring veterinarian should be notified of all major changes in the animal's medical condition. In particular, the referring veterinarian should be notified the same day, preferably immediately, if an animal dies or is euthanized at the referral hospital. This better prepares the referring veterinarian to help the client with grief counseling.

The referring veterinarian transfers primary case management and responsibility to the specialist at the time of referral, but should feel free and even encouraged to call for updates and ask questions about diagnostic testing and therapeutic decisions. When a referring veterinarian calls for information or to discuss a hospitalized patient, the specialist should make an effort to speak to the referring veterinarian at that time, rather than have a message taken. If a message is left, the specialist or his or her assistant should attempt to call the referring veterinarian back the same day the message is left. Optimum patient care occurs when the referring veterinarian and specialist have open, efficient methods of communication, whether by telephone, fax, or e-mail. Emphasizing this aspect of the referral relationship to veterinary students, and executing it as practicing veterinarians, would substantially improve client compliance and continuity of care.

Referral letters, if used, should ideally be mailed within one week of the discharge or death of any referred patient. Some referral hospitals may use a single form that combines client discharge instructions and the referral letter, whereas some may send a separate referral letter to the referring veterinarian. Client discharge instructions can be faxed to the referring veterinarian the day the animal is discharged. Referral letters should include all relevant diagnostic findings, plans for follow-up care, and some indication of whether follow-up care should or could be performed by the referring veterinarian.

Client Request for a Second Opinion

A client should never be discouraged or prevented from obtaining a second opinion or referral. The decision to refer a patient to a specialist is complicated and multifactorial. In general, any animal that has not received a definitive diagnosis or fails to improve despite medical treatment should be considered a candidate for a second opinion. The time prior to such a recommendation will vary depending on the circumstances of the animal's medical condition, the client's desire to pursue diagnostic testing and treatment, financial considerations, and a number of other tangible and intangible factors.

When considering referral of a patient, whether a general practitioner recommends referral to a board-certified specialist or to another veterinarian in the area who is not board certified but is nevertheless qualified to accept the referral is up to the general practitioner, in consultation with the client. However, caution should be exercised to ensure the client understands the nature of the expertise and qualifications of the individual to whom he or she is being referred. In the interest of client satisfaction and education, the general practitioner should explain the training and experience that board-certified specialists have. Distance to another veterinarian should only be a factor with regard to likely client compliance, and the primary considerations should be patient care and well-being. Prior to referral, the general practitioner should inform the client of the financial implications associated with further diagnostic testing and treatment. Clients and their animals often suffer when they are referred without being adequately prepared for the financial realities associated with care at a referral hospital.

Specialists have a responsibility to provide general practitioners with an opportunity to consult with them to determine whether particular patients should or should not be referred for a second opinion. However, general practitioners should respect the time of the specialists they consult and should not attempt to manage a case by telephone when referral would be a wiser course. It is recognized by the committee that a fee may be charged by specialists in situations when a considerable amount of time is being spent advising general practitioners. However, if such a fee is to be charged, the general practitioner should be notified in advance.

Specialists have a responsibility to consider referral in-house or to another hospital if they are unable to obtain a definitive diagnosis or effect successful treatment. In such instances, the original referring veterinarian for the patient should be informed of the decision to seek further referral, but the responsibility for future communications lies with the new referral specialist.

Obligation to Refer a Patient Back After Referral

Referral hospitals should attempt to ascertain who the referring veterinarian and referring veterinary hospital is for patients seen on a referral or emergency basis. If a client refuses to provide this information or requests that the regular veterinarian not be informed that the animal is being examined at another hospital, this decision must be respected. However, the specialist should make every effort to convince the client as to the benefits of communicating with his or her regular veterinarian, both in terms of obtaining relevant historical information and in terms of providing appropriate follow-up care for the patient.

When an animal is referred for a second opinion, the initial problem that prompted referral should be addressed. Other problems identified during the course of the animal's evaluation should be brought to the attention of the client and the referring veterinarian, but whether these secondary problems should be addressed at the referral hospital depends on their relationship to the underlying disease process that prompted referral, the animal's comfort, and the client's desires. In general, what is in the best interest of the animal at that point in time should be the primary motivator for whether these secondary problems are immediately addressed. In some instances, this may involve performing diagnostic tests or administering treatments normally performed or administered by the referring veterinarian. In such situations, the specialist should inform the referring veterinarian as to why the procedure was performed or the treatment was undertaken. Routine procedures, such as vaccination, heartworm testing, annual examinations, and the sale of heartworm preventatives and flea and tick control products, should never be offered by a specialist to a referred client, although rabies vaccinations may be considered an exception to this policy in some circumstances. To maintain a constructive and collegial relationship, and in the interest of fostering a long-term, mutually beneficial, and financially equitable relationship, veterinarians from the specialist's hospital should refrain from becoming the general practitioner for a referred patient.

Specialists should always encourage referred clients to follow up with the referring veterinarian if the specialist and referring veterinarian believe that the referring veterinarian is capable of performing follow-up diagnostic testing and care. Nevertheless, at times the animal's best interests may be served by following up with the specialist. If so, the specialist should encourage the client to return to the referring veterinarian for ongoing care as soon as this is appropriate. However, a referral does not end until followup care is completed by the specialist. In situations when follow-up care could reasonably be performed by either the referring veterinarian or specialist, the client should be allowed to make the final decision as to who will perform the follow-up care.

If a client expresses dissatisfaction with the referring veterinarian, the specialist should actively encourage the client to address those concerns with the referring veterinarian so that the veterinarian-client relationship can be maintained or improved. Similarly, general practitioners should encourage clients to address any concerns or complaints regarding their referral to the specialist who managed their animal's care. In both situations, the specialist or referring veterinarian should try to notify the other about the client's concerns in advance of the client's contact.

Addressing and Improving Standards of Care

Uniform standards of medical care have not, to the committee's knowledge, been established for specialists or general practitioners. That stated, professionally and legally, the standard of care for general practitioners is different from the standard of care for specialists. Specialists must be cognizant of this fact when they are evaluating or critiquing the management of a case by a general practitioner. In the absence of uniform standards of medical care, case management by a general practitioner may reasonably differ from what a specialist may have undertaken.

Specialists have a responsibility to educate referring veterinarians in cases when they believe animals may or should have been managed differently. This should be done tactfully and respectfully with the goal of improving the quality of care for a particular patient and for future patients seen by the referring veterinarian. Referring veterinarians should not be defensive or confrontational when specialists attempt to communicate new ideas or suggest other ways they may have managed patients, nor should specialists discourage referring veterinarians from providing suggestions or advice regarding case management. To encourage specialists to provide constructive criticism, referring veterinarians should not respond by withholding future referrals. Constructive criticism is an important and invaluable aspect of enhancing the level of care veterinarians provide. Constructive criticism can be included in a separate letter or a note or can be provided via a telephone call, but should not be part of the referral letter.

A client has a right to honest answers when he or she asks a specialist for an opinion on how a case was managed previously. In answering these questions, the specialist should not make comments that in any way impugn the reputation of or undermine the client's trust in the referring veterinarian without first reviewing the medical record and contacting the referring veterinarian to discuss the case.

If a client is intent on pursuing a malpractice complaint against a veterinarian, the client can be provided with contact information regarding mediation committees available in the state or the state board of examiners whose job it is to protect the public. Veterinarians have an ethical obligation to report what they believe to be patterns of professional negligence or malpractice to the appropriate authority.

Conclusion

The relationship between an animal, its owner, the general practitioner, and the board-certified specialist is complex and evolving. Failure to communicate effectively with clients and fellow veterinarians runs contrary to our stated mission of providing optimum care to our patients. Veterinarians have a responsibility to each other and to the profession to maintain and promote a professionally respectful attitude in all their communications. This will also help maintain client trust in the integrity of our profession.

The committee has, in the interest of brevity, chosen to focus on some of the fundamental aspects of this relationship and is aware of the need for further discussion and refinement of this work. Situations may arise that the committee did not anticipate, but it is hoped that this document will serve as a framework for future clarification of this increasingly important aspect of veterinary medicine.