During the past decade, access to board-certified veterinarians has increased, which has resulted in more pets being cared for by multiple veterinarians, often at > 1 facility. This availability of board-certified veterinarians benefits pets, owners, and the veterinary profession. The referral process, although routinely performed, can be complicated. There are legal and ethical responsibilities of veterinarians to clients as well as among veterinarians. The basic requirements for successful referral depend on effective 2-way communication. The referring veterinarian must provide an adequate patient history in a clear and concise format. In return, the referring veterinarian expects a timely report regarding diagnosis and treatment or management recommendations. Owners expect clear and consistent communication from both the board-certified veterinarians as well as the referring general practitioner. Failure to meet these expectations may cause frustration for all parties involved in the referral process.
The client, referring veterinarian, and board-certified veterinarian work as a team in successful referrals. One essential characteristic of highly functional teams is effective communication. Good communication creates meaningful and trusting relationships between veterinary professionals and their clients, which is a fundamental tenet of patient care. Effective communication is particularly important to the relationship between general practitioners and board-certified veterinarians. Few things are more destructive to the relationship between general practitioners, board-certified veterinarians who work at referral facilities, and clients than a perceived lack of communication, particularly when it results in a lapse of care for a pet or confusion for an owner. However, communication gaps still plague human and veterinary medicine. In human medicine, a key issue in complaints investigated by state licensing boards is the patients' perceptions that they were given conflicting information by different health-care professionals.1 In a 2003 veterinary survey2 of general practitioners, 20% reported poor communication as a reason they hesitated to refer clients to board-certified veterinarians. One barrier to effective communication is the tendency to base communication style or content on preconceived assumptions about the person who receives the information. This can be evident between veterinarians and clients, but it also may be evident among veterinary professionals.
A preliminary study3,a was conducted in Texas to analyze the veterinary referral environment in that state with regard to 4 key areas: demographic variables as predictors of referral center selection, key decision-making factors as predictors of referral center selection, needs and expectations of referring veterinarians regarding service quality at the VTH of Texas A&M University and privately owned referral practices, and needs and expectations of referring veterinarians in Texas with regard to nutritional product recommendations and sales, compared with the current practices of board-certified veterinarians. To accomplish these objectives, referring veterinarians in private practice, board-certified veterinarians and veterinarians in residency training programs at the VTH of Texas A&M University, and board-certified veterinarians at privately owned referral practices were surveyed. Of 478 referring veterinarians who responded, 431 preferentially referred small animal patients to privately owned referral practices rather than to a VTH. The primary reasons cited for this preference were convenience (358/431 [83%]) and location (328/431 [76%]). Of the demographic variables evaluated, distance was the best predictor for referral center selection because general practitioners typically referred a patient to the closest VTH or privately owned referral practice.a However, when asked about service quality, general practitioners were significantly (P < 0.001) more likely to refer patients to board-certified veterinarians who were perceived to be available and prompt with follow-up communications to referring veterinarians.3
One aspect of communication between board-certified veterinarians and general practitioners involves nutritional product recommendations and initial sales of nutritional products to a client whose animal has been referred for veterinary medical care. It has anecdotally been thought that board-certified veterinarians have been reluctant to recommend or to sell nutritional products because they believe referring veterinarians will perceive this practice unfavorably. Board-certified veterinarians at Texas A&M University and at privately owned referral practices underestimated the degree to which referring veterinarians welcomed specific nutritional product recommendations or sales to the clients that they referred.a In fact, referring veterinarians welcomed nutritional product recommendations or sales significantly more than the board-certified veterinarians believed they did. Interestingly, both board-certified veterinarians and referring veterinarians believed that referring veterinary practices can benefit financially from specific nutritional product recommendations made by board-certified veterinarians.3 Referring veterinarians also reporteda that they benefited from specific nutritional product recommendations by gaining useful information.
Analysis of the results of that preliminary studya confirmed that communication remains a critical aspect of successful management of patients. Assessing the apparent disconnect between the opinions of referral veterinarians and the perception of VTH veterinarians of those opinions with regard to specific nutritional product recommendations could reveal the need for continuous improvements in communication between veterinary professionals.
The study reported here was designed to assess whether the findings for the preliminary study3 could be extrapolated to the general population by expanding the sample pool for referring veterinarians and board-certified veterinarians. In addition, the study was designed to evaluate general communication practices between referring veterinarians and veterinarians at VTHs, with emphasis on nutritional product recommendations made by VTH veterinarians. The purpose of the study was to compare opinions of referring veterinarians and VTH veterinarians, with the intent that the results could be used to improve quality of care for patients.
Materials and Methods
Sample population—Directors of teaching hospitals at 10 veterinary medical colleges located throughout the United States (Colorado State University, Louisiana State University, Michigan State University, University of Minnesota, University of Missouri-Columbia, North Carolina State University, The Ohio State University, University of Tennessee, Virginia-Maryland Regional College of Veterinary Medicine, and Washington State University) were contacted electronically by a marketing research companyb and asked to distribute to all board-certified veterinarians and veterinarians in residency programs with small animal focus at their institution an e-mail with a link to an online survey. Paper surveys with instructions to return by fax directly to the marketing research company were mailed to referring veterinarians within a 160-km (100-mile) radius of each of these VTHs, including those within a major metropolitan area bordering this radius. The referring veterinarians were identified by searching via postal codes within the radius of the database of small animal veterinarians maintained by a research firm.c Because neither clients nor live animals were involved in this project, approval by an institutional review board was not required.
Survey—The survey was designed to obtain data on 3 categories: demographic information, discharge communication practices, and attitudes toward nutritional product recommendations.d Age and gender information was obtained for all survey respondents. Demographic information collected from referring veterinarians included average size of practice (full-time equivalent veterinarians), number of years in practice, average number of patients referred to a VTH per month, and the VTH to which they most frequently referred patients. Demographic information collected from VTH clinicians included VTH affiliation, number of years at the VTH, and, for board-certified veterinarians, their primary specialty (eg, internal medicine or surgery). Discharge communication practices were assessed by asking referring veterinarians if they were typically contacted by VTH personnel prior to receiving a completed case summary and, if so, how and by whom. They were also asked the average time required to receive a completed case summary after the referred patient was discharged from the VTH. Veterinary teaching hospital clinicians were asked if referring veterinarians were typically contacted prior to them (ie, the referring veterinarians) receiving a completed case summary and, if so, how and by whom. Veterinary teaching hospital clinicians were also asked the average time required to send a completed case summary to referring veterinarians once a referred patient was discharged. Questions intended to assess the attitudes of VTH clinicians and referring veterinarians toward recommendations on nutritional products were designed by use of item statements with a 7-point Likert scale. Veterinary teaching hospital clinicians and referring veterinarians were asked if referring veterinarians welcome, gain knowledge from, and benefit financially from the VTH clinicians making specific nutritional recommendations and if referring veterinarians welcome and expect the initial sale of specific nutritional products by VTH clinicians.
Statistical analysis—Crosstabulation tables were produced to provide the results of all target variables by the various predictor (independent) variables of interest. Crosstabulations for variables containing numeric means were evaluated by use of a t test to determine significant differences between the means. Differences between percentages were evaluated by use of z tests to determine if there were significant differences between the percentages of 2 groups with respect to a specific answer. For statistical analysis, values of P ≤ 0.05 were considered significant.
Results
Sample population—Surveys were distributed to 690 VTH veterinarians and 12,720 referring veterinarians. There were 98 (14.2% response rate) surveys returned by VTH veterinarians, and 1,430 (11.2% response rate) surveys were returned by referring veterinarians.
Demographics—Referring veterinarians typically were older (1,010/1,420 [71%] were ≥ 41 years old) than the VTH veterinarians (39/98 [40%] were ≥ 41 years old). The proportion of VTH veterinarians who were female (61/98 [62%]) was higher than the proportion of referring veterinarians who were female (730/1,420 [52%]). Most (841/1,424 [59%]) referring veterinarians reported that they were in a practice that had 2 to 4 veterinarians, whereas 424 (30%) were the sole veterinarian at the practice, and 159 (11%) were in a larger practice (≥ 5 veterinarians). The VTH veterinarians indicated disciplines of small animal internal medicine (n = 19 respondents), surgery (18; comprising soft tissue surgery [12] and orthopedic surgery [6]), dermatology (10), oncology (7), emergency and critical care (5), cardiology (4), ophthalmology (4), equine or large animal (3), theriogenology (3), clinical nutrition (2), neurology (1), anesthesiology (1), community practice (1), dentistry (1), radiology (1), and zoological medicine (1); 17 VTH veterinarians did not indicate a discipline.
Communication—Most (78/98 [80%]) VTH veterinarians indicated that they believed referring veterinarians were contacted (via phone [76/78], e-mail [14/78], or other [22/78]) before a completed, written case summary was sent to the referring veterinarians. However, a significantly (P = 0.001) smaller proportion of referring veterinarians (697/1,399 [50%]) believed this to be true. Both VTH veterinarians (76/78 [97%]) and referring veterinarians (609/681 [89%]) indicated that telephone calls were the most common form of contact.
Male referring veterinarians ≥ 41 years old typically indicated that they were contacted before they received a written case summary, which was in contrast with results for younger or female referring veterinarians. With regard to the time frame for receiving a written case summary, referring veterinarians (765/1,340 [57%]) were significantly (P = 0.001) more likely to indicate an interval of > 6 days after discharge of a referred patient, and 209 (16%) referring veterinarians indicated that it required ≥ 14 days to receive a written case summary. Paradoxically, 58 of 98 (59%) VTH veterinarians indicated that they sent a written case summary to a referring veterinarian 1 or 2 days after discharge of a referred patient (Figure 1). Female referring veterinarians < 30 years old were more likely to indicate that they received a written case summary within 1 or 2 days after a referred patient was discharged. Interestingly, a majority (66/78 [85%]) of VTH veterinarians indicated that the board-certified veterinarians were the ones who most often contacted referring veterinarians, whereas only 375 of 1,435 (26%) referring veterinarians indicated that they were contacted by a board-certified veterinarian from the VTH.
Comparison of responses between 1,430 referring veterinarians (black bars) and 98 VTH veterinarians (gray bars) with regard to the typical amount of time it requires for a VTH veterinarian to send (or conversely, for a referring veterinarian to receive) a completed, written case summary after discharge of a referred patient from a VTH. *†Response differs significantly (*P = 0.001; †P = 0.01) between referring veterinarians and VTH veterinarians.
Citation: Journal of the American Veterinary Medical Association 237, 5; 10.2460/javma.237.5.513
Nutritional product recommendations—Both VTH veterinarians and referring veterinarians over-whelmingly agreed with the statement that having pet owners feed specific nutritional products was integral to medical management. A majority of referring veterinarians (1,367/1,409 [97%]) and VTH veterinarians (89/98 [91%]) agreed (somewhat agree to strongly agree) that feeding specific nutritional products was an important aspect of patient management. Of the survey respondents, only 2 (2%) VTH veterinarians and 17 (1%) referring veterinarians indicated any disagreement (somewhat disagree to strongly disagree) with this statement.
Referring veterinarians were significantly (P = 0.001) more likely than were VTH veterinarians to agree with the statement that a referring veterinarian would welcome specific nutrition product recommendations from VTH veterinarians. A majority (1,200/1,399 [86%]) of referring veterinarians agreed (somewhat agree to strongly agree) with this statement. Significantly (P = 0.001) more VTH veterinarians (23/98 [23%]) than referring veterinarians (124/1,399 [9%]) indicated that they could neither agree nor disagree with this statement (Figure 2).
Comparison of responses between 1,430 referring veterinarians (black bars) and 98 VTH veterinarians (gray bars) with regard to the statement that referring veterinarians welcome specific nutritional product recommendations made by VTH veterinarians. *Response differs significantly (P = 0.001) between referring veterinarians and VTH veterinarians.
Citation: Journal of the American Veterinary Medical Association 237, 5; 10.2460/javma.237.5.513
Both referring veterinarians (713/1,391 [51%]) and VTH veterinarians (62/98 [63%]) were most likely to agree (somewhat agree to strongly agree) that referring veterinarians gain medical knowledge when VTH veterinarians make specific nutritional product recommendations. Referring veterinarians who reported that they gained medical knowledge were significantly (P = 0.001) more likely to be ≥ 41 years of age and in practice for > 6 years. Female referring veterinarians were significantly (P = 0.05) more likely to strongly agree with this statement than were male referring veterinarians.
Veterinarians at a VTH (38/98 [39%]) were significantly (P = 0.001) more likely to neither agree nor disagree with the statement that referring veterinarians expect VTH clinicians to make the initial sale of specific nutritional products for the immediate benefit of referred patients and thus avoid lag time for clients with regard to feeding of the recommended nutritional product. In comparison, 1,153 of 1,398 (82%) referring veterinarians indicated that they agreed (somewhat agree to strongly agree) with this statement (ie, expected these sales of nutritional products), and 491 (35%) indicated that they strongly agreed with this statement (Figure 3).
Comparison of responses between 1,430 referring veterinarians (black bars) and 98 VTH veterinarians (gray bars) with regard to the statement that referring veterinarians expect VTH veterinarians to make the initial sale of specific nutritional products for the immediate benefit of referred patients and thus avoid lag time for clients with regard to feeding of the recommended nutritional product. *Response differs significantly (P = 0.001) between referring veterinarians and VTH veterinarians.
Citation: Journal of the American Veterinary Medical Association 237, 5; 10.2460/javma.237.5.513
With regard to the initial sale of specific nutritional products by VTH veterinarians, 1,016 of 1,394 (73%) referring veterinarians agreed (somewhat agree to strongly agree) that they welcomed the initial sale by the VTH veterinarians and 280 (20%) referring veterinarians indicated that they strongly agreed with this statement. Both of these responses were significantly (P = 0.001) more likely to be made by referring veterinarians than by VTH veterinarians. The VTH veterinarians (54/98 [55%]) were significantly (P = 0.001) more likely to indicate that they neither agreed nor disagreed with this statement (Figure 4).
Comparison of responses between 1,430 referring veterinarians (black bars) and 98 VTH veterinarians (gray bars) with regard to the statement that referring veterinarians welcome the initial sale of specific nutritional products by VTH veterinarians. *†Response differs significantly (*P = 0.001; †P = 0.05) between referring and VTH veterinarians.
Citation: Journal of the American Veterinary Medical Association 237, 5; 10.2460/javma.237.5.513
Referring veterinarians (741/1,395 [53%]) and VTH veterinarians (58/98 [59%]) both agreed (somewhat agree to strongly agree) with the statement that referring veterinarians could benefit financially through future sales of specifically recommended nutritional products. Referring veterinarians from practices with 5 to 7 full-time veterinarians were significantly (P = 0.001) more likely to strongly agree that they would benefit financially when VTH veterinarians make specific nutritional product recommendations.
Discussion
In human and veterinary medicine, clear effective communication is an essential prerequisite for successful collaboration and patient management. A number of studies1,3–7 in human medicine have revealed that substantial gains in quality of patient care can be achieved by enhancing communication processes between health professionals. A variety of factors contributes to and exacerbates poor communication. These factors are often related to work-related constraints, including lack of time, pressure of work, and interruptions.1 Problem areas must be identified before communication can be improved. Results of the study reported here highlighted several key areas in which communication between referral veterinarians and VTH veterinarians can be enhanced.
General practitioners and VTH veterinarians have an apparent disconnect between the perceived effectiveness of discharge communications. The majority (80%) of VTH veterinarians indicated that they routinely communicated, primarily via telephone, with referring veterinarians before providing a completed, written case summary. However, only half of the referring veterinarians indicated being contacted before they received the written case summary. Additionally, approximately half of the referring veterinarians who were contacted were unsure who (board-certified veterinarian, veterinarian in a residency training program, or veterinary student) contacted them. A similar disparity emerged with regard to receipt of a written case summary at patient discharge. More than half of the referring veterinarians indicated it required > 6 days to receive the written case summary, whereas more than half of the VTH veterinarians indicated that they returned written case summaries within 1 to 2 days after discharge of a referred patient.
One explanation for these discrepancies may be poor communication within the hospitals of referring veterinarians. The VTH veterinarians may communicate (eg, telephone call) in a timely manner with someone other than the referring veterinarian, who is unaware that such a communication has taken place. It is also possible that written case summaries may be received and filed without being brought to the attention of the referring veterinarian. Alternatively, these discrepancies may represent a real gap in communication between VTH veterinarians and general practitioners.
To our knowledge, no studies have been conducted to attempt to quantify this communication gap in veterinary medicine. Communication gaps are the subject of a number of studies3,5,7 in human medicine. In 2008, a study6 on patient safety in Australia revealed that communication failures were a feature in 19% of reports of events general practitioners believed should not have happened, regardless of who was at fault or the outcome of the event. Close to half of the communication failures were related to poor communication with the referring doctor at discharge.5 In a 2007 report7 by an independent, not-for-profit organization that certifies health-care organizations in the United States and provides international recommendations on quality and safety of health care, communication errors were identified as the primary cause of sentinel events across all categories. Sentinel events were defined as an “unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.”7 In a Canadian study,4 investigators evaluated efforts to use communities of practice to enhance interprofessional practice in 7 clinical sites across Alberta. Participating staff were free to decide the area of practice focus and the implemented actions. Interestingly, all practice changes implemented were related to improving communications or information transfer (eg, admission and discharge processes). These practice changes contributed to better communication of information and more effective transition of patients between providers, which could potentially reduce errors.3 Given the similarities between communication in human and veterinary medicine, it is reasonable to presume that the discrepancies identified in the current study represent a real gap in communication between VTH clinicians and general practitioners.
This lapse in communication may be frustrating for veterinarians, but more importantly, it may interrupt patient care. When clients are nervous or overwhelmed by the information provided by VTH veterinarians, they often depend on their referring veterinarian to interpret the information and provide insight on issues such as quality of life. For this reason, rapid and complete communication between VTH veterinarians and general practitioners is essential. Inadequate information exchange between referring veterinarians and VTH veterinarians can impair the diagnostic process and lead to additional patient visits or redundant testing (and therefore increase costs), client dissatisfaction, and loss of confidence in the veterinary health-care team. In human medicine, patients who are dissatisfied with medical consultations are more likely to withdraw from treatment plans, seek numerous opinions regarding their illness, seek alternative forms of treatment, and lodge complaints against their physician or initiate legal proceedings to seek compensation.6 Interestingly, in human medicine, malpractice cases in which miscommunication between a specialist and primary care physician, rather than misdiagnosis, was the primary cause for litigation, indemnity awards were twice as high as when there was appropriate communication.4
One aspect of communication between general practitioners and board-certified veterinarians is with regard to specific nutritional product recommendations from VTH veterinarians. Results of a preliminary studya supported anecdotal reports that board-certified veterinarians may be reluctant to make specific nutritional recommendations or sales, not because this practice is considered medically unnecessary but because they are unsure how it will be perceived by referring veterinarians. In the study reported here, a marked discrepancy existed between the opinions of referring veterinarians and the perception of the referring veterinarians' opinions by VTH veterinarians, despite the fact that both overwhelmingly agreed that having pet owners feed specific nutritional products is integral to medical management.
Lack of adherence to medical recommendations is often the result of poor communication.8 On the basis of the findings for the present study, at least half of the referring veterinarians were unaware of the recommendations of VTH veterinarians until 1 to 2 weeks after a referred patient was discharged from the VTH, rather than the 1 to 2 days estimated by the VTH veterinarians. Additionally, this study confirmed that VTH veterinarians throughout the United States consistently underestimated the referring veterinarians' acceptance of specific nutritional recommendations and sales and the expectation that VTH veterinarians would make an initial sale. The combination of board-certified veterinarians who avoid making specific nutritional recommendations or sales because they are uncertain how referring veterinarians perceive these actions, as well as gaps in communication between the VTH veterinarians and referring veterinarians, results in patients being less likely to receive recommended nutritional management in a timely manner.
Conclusions
The study reported here confirmed that communication gaps exist between general practitioners and VTH veterinarians. The breakdown in communications that are evident throughout the referral process is a result of procedural and attitudinal issues. Identifying procedural issues related to delivery and receipt of discharge instructions should be investigated by VTH veterinarians and general practitioners. On the basis of the results of this study, board-certified veterinarians should not presume to know the attitudes of referring veterinarians, particularly with regard to specific nutritional recommendations and sales. Failure to discuss specific nutritional recommendations prevents effective consultation between veterinarians but also directly affects clients who may experience delays in treatment for their pets.
ABBREVIATION
| VTH | Veterinary teaching hospital |
Bell D, Brzozowski G, Crim MJ, et al. Analysis of small animal veterinary referral industry in Texas from 2001–2005 with perception gaps in nutritional recommendation. MBA thesis, Mays Business School, Texas A&M University, College Station, Tex, 2006.
Applied Marketing Research, Kansas City, Mo.
Datacore Marketing, Westwood, Kan.
Copies of the survey are available on request.
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