Background

Traditionally, lack of access to care was described as a population of pet owners that cannot afford veterinary care. Currently, the growing pet healthcare gap extends beyond solely financial resources with a focus on the availability of veterinary professionals. More specifically, the perception that the current veterinary professional workforce is not timely satisfying pet healthcare demand and will continue to struggle to meet these demands going forward.

During the pandemic, reduced or lack of access to veterinary hospitals, longer wait times for patient appointments, and more patients in need of critical care were considered the norm.¹ While the pandemic did not create the demand for pet healthcare, it has been attributed to amplifying increases in pet ownership, veterinary labor shortfalls, and the underlying rationale to continue to work in practice.² A pandemic-induced 5-fold increase in the growth rate of net pet additions drove demand for veterinary care to new heights.² Both veterinary professionals and pet owners have expressed concerns that the availability pre-pandemic was not meeting the present demand in companion animal and specialty practice, not even considering traditionally underserved areas across veterinary medicine. With wages rising nationally at the fastest pace in decades many clinic owners are paying more to keep and find employees in this labor-intensive profession.³

Currently, most veterinary clinics have consistently full schedules and a complex caseload. Some practices, operating with full schedules, may still accept sick patients to either wait or be dropped off so staff can “work in” diagnostics and treatment when time permits. Others are not accepting new clients and may offer the option of being placed on a waitlist. If clients cannot obtain a timely appointment, they may opt to use an urgent care facility. Studies indicate only 47% of pet owning households spent money on veterinary services during 2021 but the results do not include rationale such as if this may have been due to the difficulty in scheduling appointments, long wait time, or substitutes for veterinary services that can be attributed to shortages.⁴ Overloads are also being experienced by veterinary urgent care and specialty practices.⁵

Despite the greater veterinary capacity need, veterinary staff are not seeking more hours or an increased patient caseload.⁴ An Idexx analysis suggests 21% of US practices reduced or eliminated weekend services in 2022.^2,6 A 2019 national study by the AVMA Veterinary Economics Division reported an additional 4,500 full time equivalent veterinarians would be needed to make up for veterinarian’s collective net desire to work fewer hours and accept less compensation.^4,7

The available trend information on the future demand and supply of veterinarians in companion animal medicine requires an analysis of several critical factors. This includes: the demand for pet health services; veterinary school enrollments; and pet healthcare spending; career attrition rates for veterinarians; and immigration of foreign veterinary graduates. Unfortunately, reports from Animal Health Economics, LLC, a recent Idexx model of veterinary visit demand, and cites of expanded household pet population demonstrates a widening gap between the demand for veterinary visits and veterinary capacity by 2030.^2,4

The American Pet Products Association estimates that 86.9 million US households owned pets in 2023 showing an annual compounded growth rate of +1.5% in the total US pet owning households.⁸ A conservative estimate of pet healthcare spending is expected to increase 3% to 4% per year beyond inflation over the next 8 to 10 years resulting in the need for an additional 123,267 to 133,173 veterinarians by 2030.⁴ In addition to the veterinarians needed to meet the increase in demand, there will be additional 15,500 veterinarians needed to replace those that leave the profession due to retirement and other reasons by 2030.^9,10 An Idexx model of this gap implies an estimated 40% increase in veterinarian productivity is required to fulfill expected 2030 demand for pet healthcare.²

As cited earlier, many veterinarians feel overworked and would like to decrease their hours despite working more hours struggling with burnout and work-life balance.⁷ It is estimated with projected growth and anticipated separations there will be a total of about 45,000 to 55,000 additional companion animal veterinarians will be needed in 2030.⁴ Lori Teller, DVM, DABVP, AVMA Past-President, in a personal email communication (August 2, 2023), clarified that, while the AVMA Economics report showed a desire to work fewer hours, most companion animal veterinarians have not actually decreased the number of hours worked.

When we consider companion animal veterinarian shortages, we need to also consider new veterinarians entering the workforce. This number is expected to increase with the development of new schools, increasing class sizes at current schools, and foreign trained veterinarians that have passed the North American Veterinary Assessment.⁴ In 2022, an estimated 86,947 veterinarians were actively working in companion animal practice.⁴ It is estimated that this will increase the US pet healthcare workforce by 2030 with 31,000 new companion animal veterinarians.⁴ Despite the new graduates, it is projected that a shortage of 14,000 to 24,000 companion-animal veterinarians (11% to 18%) could well exist in the US pet healthcare market by 2030.⁴

An overburdened work environment creates the potential for necessary steps and potential diagnoses to be missed, including medical record-keeping errors or omissions and lack of ability to obtain a timely referral. These factors may result in client complaints and potential legal liability. Veterinary defense attorney Christopher S. Patterson, Member, Fahey Schultz Burzych Rhodes, Okemos, Michigan (personal email communication, September 2, 2023) summarized that in his practice the increase in demand for veterinary services has resulted in clinic referrals to emergency clinics and subsequent client dissatisfaction. Similar experiences are being reported by the AVMA Trust.¹¹ In a recent newsletter, “Veterinary License Defense: Don’t Practice Without It,” AVMA PLIT documented an increase in license discipline claims.¹¹ The most common cause of a license discipline complaint is failed expectations or a bad outcome for a patient.¹¹ They have also noted that owner expectations have changed and the value that is placed on pets and other animals has also changed leading to an increase in dissatisfaction and complaints.¹¹

This viewpoint does not address the perceived shortcomings in the veterinary medical workforce nor propose solutions to the gap. We will explore legal and ethical considerations for companion animal practitioners focusing on the increased risks that may result from staffing challenges in an overburdened clinic environment.

When Does a Veterinarian Have a Duty to Provide Care?

Since we are discussing a lack of access to veterinary care first, let’s review when there is an actual legal duty to provide care. We can’t address this without considering how to legally establish, maintain, and terminate the veterinarian-client-patient relationship. The veterinarian-client-patient relationship (VCPR) serves as the basis for all client and patient interactions with the veterinarian. We will also consider the ethical duties of a veterinarian to provide care.

The AVMA Principles of Veterinary Medical Ethics Principle 7 states, “A veterinarian shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment which to provide veterinary medical care.”¹² However, once you assume that duty by entering a VCPR, you are required to continue to provide care until the patient is stable and has access to follow-up care.¹² For example, in Washington a veterinarian is “free to accept or reject a particular patient, but once care is undertaken, the veterinarians shall not neglect the patient, as long as the person presenting the patient requests and authorizes the veterinarian’s services for the particular problem.”¹³ Other states have specific language clearly stating that veterinarians have the right to refuse to render veterinary medical services for any reason or to refuse an owner’s request to euthanize a healthy or treatable animal.¹⁴

Some states have legal requirements for a veterinarian to provide care to animals under specific circumstances, usually during an emergency. In Pennsylvania, a veterinarian has a moral and ethical responsibility to provide service when, because of accidents or other emergencies involving animals, it is necessary to save an animal’s life or to relieve its suffering.¹⁵ In states that do not have a legal requirement to provide lifesaving or emergency care, such as Michigan, the requirement to provide care may be based on the AVMA’s Principles of Veterinary Medical Ethics that a veterinarian has, at a minimum, a duty to relieve animal suffering.¹²

In an emergency or life-threatening situation there are times when the best option is euthanasia, which makes some veterinarians uncomfortable. Increased resources are available to help educate veterinarians on the intentional termination of the animal’s life to either relieve or prevent suffering.¹⁶ When the informed client gives valid consent, euthanasia is an appropriate intervention to relieve suffering.¹² When the owner is not known, euthanasia without the owner’s consent may also be appropriate.¹²

When discussing access to care, one of the frequent solutions proposed is for states to allow for more a lenient use of telemedicine to address both routine and sick patient needs. The veterinarian’s compliance with state and even federal requirements to legally establish, maintain, and/or terminate the VCPR may prevent the veterinarian from providing pet healthcare under certain situations. The use of telemedicine and the patient does not present for a physical hands-on exam.¹² Virtual care does not allow, by its nature, for an in-person examination. This may be required based on the jurisdiction and/or scope of care to establish and/or maintain a VCPR. State requirements may include that the veterinarian have sufficient knowledge of the patient based on physical examination, medical records, and the ability to provide follow-up care to satisfy the VCPR. Absent this valid VCPR legal relationship, the veterinarian may open themselves up to both civil and administrative liability for providing care for an animal. A state disciplinary body’s determination of whether a valid VCPR exists will again boil down to an evaluation of medical records, including documented client communications.

It is important to note that in most jurisdictions teletriage may be performed outside an established VCPR. This would allow the veterinarian the ability to provide immediate care virtually and direct the owner to the closest facility for subsequent care. Teletriage, as defined by the American Association of State Veterinary Medical Boards, is “emergency animal care, including animal poison control services, for immediate, potentially life-threatening animal health situations (e.g., poison exposure mitigation, animal CPR instructions, other critical lifesaving treatment or advice).”¹⁷

Absent detailed state requirements, ethically, if you decide to terminate the VCPR you should follow the AVMA’s Principles of Veterinary Medical Ethics.¹² As previously discussed, to do so, you will likely need to ensure the animal no longer needs care or have adequate assurances that the patient will be under the care of another veterinarian. Conversely, a client can terminate the relationship at any time.¹²

It is important that veterinarians are familiar with state licensing requirements. This will inform what is required to practice in a state and the resulting duties. If a complaint is filed, the states could review the facts to determine whether the alleged conduct was unethical or unprofessional resulting in disciplinary action. Veterinarians should continue to work with colleagues and local organized veterinary medicine to advocate for pet healthcare services to be available to the public consistent with local needs.

What Level of Veterinary Medical Care is Required to Meet the Standard of Care?

Standard of care is a legal concept. The standard of care should be distinguished from the standards of practices of a profession, which are factual conclusions. Often the legal standard of care and professional standards will be coterminous, but not always. It is important to note that the minimum standard of care is not a “best practice” or “gold standard” but the minimum level of acceptable care.¹⁸ For purposes of our discussion, the minimum level of acceptable care will be referred to generally as the standard of care unless noted otherwise in the remainder of the viewpoint. While state administrative proceedings loosely use the term standard of care, most state law regulatory frameworks are concerned with whether the minimum required by state law was met as established by experts.

The standard of care is not a universally accepted set of practice guidelines. This creates challenges in characterizing under a set of facts the level of care that may be deemed below the standard of care by a court, licensing board, or even colleague. Veterinarians are encouraged to engage in dialogue with other colleagues to better assess what colleagues feel is an acceptable minimum level of care. The veterinarian may want to conduct research (such as checking with a local university or an online discussion forum) and the communications should be documented. This will help veterinarians better conform with the legal standard of care if the level of care provided is called into question and evaluated by peers.

Spectrum of care has recently been defined in the veterinary literature as “the wide range of care options that veterinarians can provide.”¹⁹ Veterinarians have expressed concerns about potential liability for failing to meet the state’s required minimal level of standard of care if they provide a spectrum of care.¹⁹ However, a veterinarian not providing the client with a spectrum of options may result in a complaint or legal recourse. Conversely, a veterinarian may offer choices but the diagnostic and/or treatment plan may be limited by the client. In this situation the veterinarian needs to clearly document the options offered to include the potential (good and bad) outcomes associated with the options, and also the client decision in the patient medical record. During a time of limited or decreased availability of specialists and overall staff resources, these concepts of spectrum of care, informed client consent, and communication will be even more important to understand and effectively implement in practice.

Schedule and Staff Considerations

Veterinary practice structure may contribute to both legal liability and burnout. Burnout may result from a lack of autonomy, practice efficiency, and expectations around workloads. Inefficient staffing may be due to a range of issues such as inappropriate staffing models, lack of empowerment of staff; paucity of training; and/or inadequate level of supervision available.² Some of the schedule and staff considerations that have led to veterinary state license complaints include: support staff giving medical advice that was considered the unauthorized practice of veterinary medicine; tasks not being performed by licensed veterinarians; an absence of a veterinarian onsite for patient’s healthcare needs; and failure to provide continuity of care. We will consider some examples below where staffing and scheduling can create potential liability in companion animal practices.

Many states are revisiting the defined scope of practice in their state practice acts and specifically clarifying the authority or lack of authority to delegate tasks to professional staff, the type of staff member that can perform the duty, and the type of tasks that can be delegated.²⁰ It is important to ensure that a task can legally be delegated by a veterinarian to a member of their team. This will not only require the veterinarian to ensure that the duty does not constitute the practice of veterinary medicine but also ensure that the delegee has the appropriate level of training and supervision to competently carry out the delegated task.²⁰ One should not delegate a task that you cannot competently perform yourself. There are also requirements for the physical proximity that a treating veterinarian must be within a delegate (whether licensed or unlicensed). It is important to ensure the integrity of the veterinarian-client-patient-relationship is protected while also maximizing staff resources. These trends highlight the need to stay up to date on changes to your state practice act.

Advertising that a clinic is open to provide care within the scope of the practice of veterinary medicine when a veterinarian is not ready and able to provide care is unwise. A client basing their decision to bring their animal experiencing an emergency to your clinic versus one down the road may be based on your posted hours. If your reception stays open until the posted close of business, but medical staff are not available, informing the public is advisable. It is best to communicate before the client arrives if you do not offer overnight care or have no overnight medical staff available. Document who communicates this to the client and note it in the medical record.

A team approach to care is another area that will require an evaluation of the veterinarian-client-patient relationship. If the clinic employs a team-based approach, this needs to be communicated to the client as relevant to their pet. Confusion arises when an animal is dropped off for a “work in” appointment or is hospitalized. The client may assume a certain individual will be providing the care. Identifying who is responsible for the care, communications, and changes in agreed upon treatment plans is often critically important to clients and requires client consent before proceeding. As we consider the duration practices stay open to satisfy the need for care, we also need to address who will be providing care during shift changes or during overnight care needs if offered. Documenting in the medical record who provided what care to a patient, and if required supervisor oversight, will be critical in ensuring that the team has provided continuity of care for the patient. While this may seem like additional tedious steps and record-keeping, an increase in team productivity is noted with greater clarity around the roles and responsibilities of the veterinary team and improved scheduling of care.

Veterinarian Client Communications

Trends in issues before state veterinary license boards discipline committees seem to start and stop with communication between the veterinarian and staff, veterinarian and client and the recordkeeping that supports the level of communication. When time and staff resources are at a premium, consider utilizing client education materials that are artfully drafted for specific issues and also staff-led education. Identifying and addressing the client’s priorities from the start of the visit will help address the client’s concerns more succinctly and accurately in the medical records. Developing and implementing efficient protocols for documenting the communications that occur ideally in real time is key. Technology can aid in communication.

One communication pitfall noted is a veterinarian assuming that a consent form is the same as client consent. Remember a consent form is not the consent, but documents that the shared decision-making process has occurred between the veterinarian and the client.²¹ Start this shared decision-making process before the client arrives at the clinic. Provide handouts and resources for clients to take home so they can be better educated on the recommendations you have made for their pet. This will give them time to review and discuss with other members of their family.

The format of the consent form should be appropriate to meet your needs. A lengthy document with many words on a page, legal terminology, and presented without the time for thoughtful review does not accomplish the goal of client consent. Instead, think about drafting consent forms that consist of multiple bullets that include a 1- or 2-line summary of what you have discussed and let the client initial each bullet. The consent form should adequately document what was discussed, handouts provided, and the diagnostic and treatment plan that both the veterinarian and client agree to implement. You should also make it clear both in oral communications and on the consent form that if the client changes their mind or has questions at any time the client should reach out. As always, update the medical record in a timely manner to include what was provided, discussed, and the decision.

Unfortunately, it is far too easy for a state veterinary medical board and experts to use 20:20 vision and look back at an adverse outcome and question why if certain things were reported, consented to or discussed it was not included in the medical records. Some experts take the position if it was not in the medical records, it must not have happened. This is where using staff and technology can allow for the busy vet to still ensure complete medical records. This approach will minimize the potential for client dissatisfaction and subsequent liability, and likely will help the veterinarian obtain valid informed client consent.

Focus on Prevention

The pandemic highlighted the importance of preventive care. As noted in The Atlantic, “Great Veterinary Shortage” article, when general practitioners are too busy, pets who can’t see them for routine or preventive care end up needing emergency care.¹ Likewise, many pet related issues can be prevented if detected prior to the illness and avert urgent/emergent care needs. A February 2023 publication by Idexx titled, “Finding the Time: Empowering Veterinary Teams to Get the Most Out of Every day,” hypothesized that running routine blood work as part of a wellness visit does not need to conflict with productivity.² It can also be objectively quantified resulting in its use as a proxy for the level of care provided as a constant.² A greater focus on preventive healthcare can enhance the efficiency of veterinary practice, improve patient outcomes and decrease the overall cost of care.⁴ Pro-actively focusing on preventive care will help decrease the likelihood of the pet in need of emergency care and unable to find care when time is of the essence.

A review by Animal & Veterinary Legal Services, PLLC of FY22 state license disciplinary cases reflected multiple actions taken for the failure of a veterinarian to offer clients the option of additional diagnostics. These case examples include a failure of the veterinarian to offer the client: blood work or radiographs for a dog that presented with a seizure; culture for an unhealing wound; and cytology for a mass that the veterinarian eye balled as “likely nothing.” Unfortunately, this author has noted many cases where veterinarians are uncomfortable asking clients to spend additional resources on routine diagnostics without a patient presenting with a problem. The failure to offer laboratory diagnostics to a client has resulted in license disciplinary actions regardless of whether this failure resulted in an adverse event. This is also a good place to note that failure to interpret and document results in the medical record and follow-up with the client on diagnostic results has also resulted in state veterinary license disciplinary action.

Helping clients prepare for the preventive care that their patient needs will help reduce the more serious cases that progress while waiting for an available appointment during these busy times and increasing shortages. It will also help with client dissatisfaction as they are faced with unexpected medical needs and expenses for their animal. Document all the recommendations and client’s decisions in the medical record.

Standard Operating Procedures

Your clinic likely works as a team, especially under stress. Everyone has their role and the operations of the clinic most often flow as “it has always been” done. However, these operating procedures are more difficult to substantiate if called into question later when they have not been memorialized in writing. While participating in a deposition someone may quickly forget or have a differing opinion of something you believed was standard protocol. In addition to clinical procedures, it is best to clearly define roles and responsibilities for your team. Standard operating procedures are critical written procedures that can mitigate against potential legal risks as well. In a contested case, these procedures may be significant if one can demonstrate that a written procedure was follow and an adverse result still occurs.

The key to good standard operating procedures is to ensure the staff are trained in using them alongside the veterinarians so that the clinic can operate as a cohesive team. This will help everyone to be aware and to watch for potential issues especially when the veterinarian staff may be more overburdened than the remaining assisting staff. It is advantageous working with less-than-optimal staffing and new staff to document the steps of specific procedures to include how and who does specific tasks. It is especially important if patients are transferred, shift changes occur, that the client is informed and consents to the procedures. If a task is delegated, identify the person that has provided the care and if a task was delegated to a team member document it in your record. Documentation in the medical record and referenced in written standard operating procedures is useful for the clinic when questions of complaints arise.

Given the turnover in recent years, 1 clinic implemented a helpful practice when onboarding new staff. This clinic requires all new staff to read and initial all their clinics standard operating procedures and keeps them in the employee file to demonstrate that the individual had knowledge of them, were trained in them, and had the opportunity to ask questions as a new hire to the clinic. Standard operating procedures can help satisfy documentation gaps, prevent errors, reduce staff stress, and help improve workplace culture.

Medical Record-Keeping

It cannot be stressed enough the need to properly document patient care. The medical record serves as both a legal document and communication tool. The medical record needs to clearly document thought processes, client communications, and the steps taken. It is critical for continuity of care if the patient needs to be transferred.²² Practices should consider the value of digital record information and software management programs. Analyze workflow needs to ensure Subjective, Objective, Assessment, and Plan (SOAP) notes, diagnostic interpretation, discharge instructions, and client communications are succinctly and accurately documented in a timely manner.

The medical record is your third-party witness in the event your care is called into question. The timeliness of your entry is important. Some states require contemporaneous record-keeping. While this may not always be in real time, it is important to ensure that the patient care and client communications are documented accurately. Often record-keeping is delayed due to the veterinarian needing more time to record the information especially when there is a heavy caseload and less resources. There is a balance. Drafting a lengthy patient chart will not help but make it more challenging to highlight the thought process to date and identify the plan. The medical record is invaluable to make sure everyone on the team is on the same page, including the client.

Staff shortages that result in an overburdened profession and more critically ill patients make the burden of meeting the standard care more of a challenge. The medical record will be the basis for determining if the care provided met the minimally acceptable standard. If a complaint is later filed, you need to be able to provide a legally defensible record, which is hard to do without a complete, contemporaneous medical record. Invest in the right medical record keeping program for your practice and consider new technologies that can make medical record keeping easier and more efficient. Practice record-keeping strategies and commit to ongoing improvement. Make sure the record reflects your professionalism, the quality care provided, and facilitates continuity of care.

Prioritize Team Well-Being

Staff shortages and overburdened practices contribute to burnout. Burnout has been defined by the World Health Organization as an “occupational phenomenon” and characterized by 3 dimensions.²³ These dimensions include feelings of energy depletion or exhaustion, increased mental distance and negativism or cynicism toward ones job, and reduced professional efficiency.²³ Burnout may result from excessive workloads, imbalance between job demands and skills, a lack of autonomy, and prolonged work stress.²⁴ Burnout affects a veterinarian’s ability to attend to patient’s effectively and efficiently.²⁴ While preventing burnout may be viewed as part of individual self-care and balance of work and life it is more effective to address this from an organizational level. Industry wide actions that include ensuring greater access to wellness resources, improving communication, optimizing workflow, and pursuing projects that target individual concerns will help to promote wellness at an organizational level.²⁴

Prioritizing staff well-being is part of prioritizing patient outcomes—if staff are suffering, so may the quality of care. Danny Rosenmund, CLEAR Blueprint Program Manager at Not One More Vet stated in a personal email communication (March 29, 2023) that the key is to engage your veterinary team. When engaging, think about how individuals interact with their environment and culture at work. Engaged staff are more productive, make fewer mistakes, and report improved well-being. Inspiring engagement from each staff member will vary. Offering staff training is a great way to improve efficiency, empower support staff, and reduce liability. Organizations fostering an environment and culture that supportively promotes staff performing to the best of their ability will likely see improvements in a variety of capacities, including improved retention, fewer mistakes, and improved reported well-being. Organizations fostering mentally healthy workplace cultures see reduced turnover, improved staff retention, and lower costs. If you can prioritize team well-being, you will likely improve staff and client interactions, prevent burnout, and result in better patient care.

Preventing Liability

The recommendations above should be considered good practices but are even more important to implement with increased resource demands on veterinary clinics. When practices are overwhelmed due to staffing issues, there are additional steps that should be taken to ensure client satisfaction and quality of care is not compromised. A failure of veterinary medical care may lead an animal owner to pursue a state veterinary medical license board complaint, legal recourse, or both. Many such claims are the result of poor communication rather than professional negligence. Working to ameliorate the impact of staff limitations and consistently striving to provide more positive outcomes for our patients, clients, and veterinary teams will help minimize potential complaints and legal liability even when working in an overburdened environment. Maximizing staff efficiency, improved written and oral communications, emphasis on preventive care, memorialization of standard operating procedures, and prioritization of staff well-being are all beneficial practices. Learning to be more productive to meet increasing demands on the profession while minimizing potential liability is challenging but doable.

Disclosures

The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.

Funding

The authors have nothing to disclose.