What are the limitations of general practitioners (GPs) and specialists?
About a year ago, I saw a dog referred for severe immune-mediated thrombocytopenia. The dog spent about a week in our hospital, receiving around-the-clock care due to severe GI bleeding and resultant anemia.
The PCV was about 10 percent despite multiple transfusions. I discussed the risks, merits and costs of remaining options with the client, and a mutual decision was made to proceed with splenectomy. I scheduled the procedure with a board-certified surgeon, and called the referring veterinarian to provide an update.
At this point, I felt stuck in the middle between pleasing my colleague who referred the case, and my advocacy to the pet whom I felt would not benefit from being moved back and forth. We decided that I would offer the client both options, ensuring she knew that surgery with the specialist would be more costly, and let her make an informed decision. At the end of the conversation, I jokingly told the veterinarian that I could also have considered doing the splenectomy. He responded by saying, "You can't do surgery; you're a specialist in internal medicine. I, on the other hand, can do everything; surgery, medicine, oncology, dermatology and ophthalmology."
By performing a residency and becoming board certified, most specialists have overtly acknowledged their strengths and limitations; that is, I would never consider performing major surgery on someone's pet for multiple reasons:
I would be liable to the standard of care available in our community if I did the surgery, and did not provide the client with all available options.
In fact, when I do diagnose surgical disease in my client's pets, they often ask me "Will you be doing the surgery, doctor?" I often chuckle at the thought, and respond, "You don't want me performing this surgery. We will put Muffy in the hands of a specialist at these types of procedures."
Practitioner limitationsI got the impression that the referring veterinarian in this case saw very few aspects of medicine and surgery that he felt he was not an expert in. What factors should influence the decision as to when a GP should consider that he/she may not be the one best suited to care for a particular pet?
Alternatively, if you operate a GDV, and the dog dies unobserved overnight two miles away from an emergency hospital, it looks bad if you didn't discuss/encourage this option.
Specialist limitationsThe limits of the knowledge of the specialist can be a double-edged sword. While he/she may be the best person for the job to treat the patient's Cushings disease, the specialist may ignore or diminish the impact of the old-age arthritis that treatment has unmasked on the pet's quality of life.
Surgeons have often been accused of rushing to cut. Is the surgeon the best person to ask whether an asymptomatic 14-year old Golden Retriever with hepatic masses should undergo a hepatectomy?
Let's consider two scenarios.
Mrs. Smith brings her dog to the oncologist for consultation on a diagnosis of lymphoma. No phone call or paper work is available to the specialist prior to the client's arrival. Generalized lymph node enlargement is confirmed. As soon as the specialist mentions the word chemotherapy, Mrs. Smith becomes very upset, and proclaims that she would never do that to her dog, and storms out of the exam room. The oncologist staggers out of the room, wondering what could possibly have elicited such an irrational, negative reaction. The referral letter is written later that day.
Mrs. B is the next appointment. Her dog has the exact same problem, but her visit is preceded by copies of the cytology confirming the lymphoma, as well as a phone call in which the GP informs you that Mrs. B just lost her brother to cancer and she perceives that chemotherapy was detrimental to him.
You broach the topic of chemotherapy very gently, taking pains to make clear that the goal is an emphasis on quality of life, that lower doses are used, and dogs seldom are made ill. The chemo is elected, and the dog does well.
The knowledge about the client that is privy to the GP is often of significant value to the specialist in helping to ensure compassionate and effective medical care of the pet.
Are there specialists who violate these rules?
You bet. Are there general practitioners that appreciate and acknowledge their limitations, and refer based on this insight? For sure.
Yet, by their choice to limit their career area of expertise, I believe that specialists are more apt to appreciate their respective strengths and limitations, than are general practitioners.
This is not to suggest that there is a difference in empathy or consideration between the two groups. I simply believe that the onus to respect one's limitations is greater on the part of the general practitioner, because this must be governed by your conscience and an objective evaluation of your professional strengths and weaknesses.
When the general practitioner and the specialist appreciate the boundaries of their respective areas of expertise, communicate well and work as a team on behalf of the best interests of the pet, the well-being of our patients is best served.