Amanda L. Donnelly, DVM, MBA
The financial success of specialists is in large part dependant on general practitioners in their community referring cases. Referring veterinarians rely on specialists to provide specialty care for their patients and to assist in the management of critical or more serious cases. The relationship between specialists and referring veterinarians is mutually beneficial to both groups. However, areas of discord exist at times between the groups and may seem more prevalent in light of the increase in availability and number of specialists in the private sector.
These proceedings outline some of the challenges and issues regarding the specialist-referring veterinarian relationship and provide suggested solutions to enhance communication and collaboration.
Common Communication Challenges
Effective communication is the foundation for any good relationship and individuals that communicate effectively will have a dialogue. Dialogue is characterized by mutual respect and understanding. It implies a conversation, not just one party talking to another. Specialists and general practitioners should strive to create a dialogue when communicating. To facilitate open lines of communication and dialogue, specialists and referring veterinarians need to take efforts to know one another. It is much easier to communicate with someone you know and have established rapport with. When specialty practices first opened, this was much easier. It was common for the few specialists in a community to get to know all the area veterinarians and to have time to devote to communication in person and on the phone. As the number of specialists and specialty hospitals has grown, specialists find it increasingly difficult to know all their referring veterinarians and to find the time to devote to phone consults. Likewise busy practitioners may have multiple specialty hospitals to send cases to and do not take the time to get to know all the specialists in town. Unfortunately, when specialists and referring veterinarians do not have an established relationship, misunderstandings and critical attitudes are more likely to occur.
Specialists spend a considerable amount of time on the phone, both with pet owners and referring veterinarians. One of the most frustrating situations can be playing phone tag with general practitioners who are unavailable when they return calls-often because they are at lunch or in an exam room. Those specialists that return calls in the evening after area veterinary practices have closed find it difficult to reach referring veterinarians if they did not leave a cell phone or home phone number where they can be contacted.
Many specialists express frustration with respect to the medical records that are sent by referring veterinarians. The most significant complaint is that the records do not include a medical case summary. Other concerns include illegible handwriting on records, incomplete records, volumes of medical history that are not relevant, missing laboratory data and missing radiographs. Many specialists also report that very few referring veterinarians fill out their referral forms.
Follow-Up Referral Reports
For general practitioners, one communication concern often cited is the lack of timely follow-up from specialists regarding referral cases. Referring veterinarians may have clients calling them to discuss their pet's condition and want to be prepared to talk to the owner. With respect to ongoing communication, some referring veterinarians want to be called after a case is referred and request daily progress reports while others are content to receive a faxed report and updates only when the status of the case changes or becomes critical. General practitioners also like follow-up reports to clearly outline the treatment plan for the pet so there is no confusion about ongoing case management.
Establishing Client Expectations
Establishing appropriate expectations with pet owners about the referral process is important for both referring veterinarians and specialists. When pet owners do not clearly understand what to expect when they visit specialty practices, they may become frustrated and feel that the veterinarians are not communicating effectively. This situation can reflect negatively on both practices. The most common complaints regarding client expectations are misunderstandings regarding the cost associated with referrals, the need to repeat tests, the severity of the pet's condition, and delayed scheduling of surgeries or procedures. The most difficult client communication challenge can occur when the specialist informs the pet owner that their pet has a different condition or prognosis than the referring veterinarian diagnosed. In addition, communication problems arise when general practitioners refer patients for a specific test or procedure rather than a specialty consult. If the specialist determines the pet does not need the procedure for which it was referred, clients can become confused and angry.
Relevant Issues and Hot Topics
Economic Challenges and Fear of Loss of Income
Small animal practitioners face a variety of economic concerns today such as the loss of vaccine income, a decrease in sterilization procedures, income lost to over-the-counter medications and internet pharmacies, lack of business skills by veterinarians, downturns in the economy, and increasing student debt. Some practitioners regard referral of cases to specialists as another area of potential lost revenue. Increasingly, general practitioners think twice before referring patients to specialists and are more likely to perform procedures such as ultrasound at their practice rather than referring these cases. Referring veterinarians are also often concerned about cases seen at emergency or specialty hospitals being sent back as soon as possible for follow-up at the general practice.
Specialists also face economic challenges such as maintaining a profitable caseload in order to support high overhead expenses. In many communities, specialists now face competition from other specialty practices in the area. Some of the most common economic frustrations reported by specialists include: timeliness of referrals by area veterinarians, referring veterinarians' lack of awareness or knowledge regarding when to refer patients, referring veterinarians misjudging clients' willingness to pay for specialty care, and limited awareness of pet owners about the availability of specialists.
Timeliness of Referrals
One of the biggest concerns of specialists is receiving patients on referral that should have been sent earlier. In some cases, patients experience prolonged hospitalization, more complicated case management or may die due to the delay in seeking specialty care. The reasons cited for failure to refer cases in a timely manner include fear of loss of income, client's unwillingness to accept a referral, lack of knowledge about when to refer cases, and general practices that feel they can manage the case without a specialist consult.
Who will be responsible for case management after a pet has been discharged from the specialty hospital needs to be established. Some referring veterinarians want to do as much follow-up care as they can while others are content to have specialists provide on-going care for patients they refer. The issue of case management also comes into play when pets are seen at night or on the weekend at an emergency clinic and then require surgery or continued care once the general practice resumes normal hours of operation. Some referring veterinarians want their patients to be sent back to them for care while others are happy to have the case referred internally to specialists. Problems can arise when the requests of the referring veterinarian to have the case sent back conflict with the pet owner's wishes or the assessment of the emergency clinician that the case needs to be referred to a specialist. Since area veterinary practices have different capabilities and requests regarding follow-up case management, specialists can find it difficult at times to keep track of all the preferences of each referring veterinarian.
Charging For Phone Consults
Due to certain issues with case management, some specialists have considered charging for phone consults on cases that are not currently under their care. This issue has come about for several reasons. One occurs when referring veterinarians routinely request that specialists evaluate laboratory findings, ultrasound images or radiographs that have been performed at the general practice. Understandably, specialists feel they should not be asked to provide their expertise for free when they are not receiving compensation for the testing or an office call. The consideration of charging for phone consults also comes up when general practitioners repeatedly call specialists for information but never refer cases.
Another concern with phone consults that is increasingly being discussed is the issue of liability and patient advocacy. Specialists are concerned that they could be held liable if they offer medical advice for a case that may not be appropriate since they cannot examine the pet. Even if they have seen the pet previously, if a significant amount of time has passed, the pet's condition may have changed and it is in the patient's best interest to be referred for a follow-up consult.
Develop Practice Tools and Protocols
The best way for specialty practices to address some of the communication challenges and relationship issues with referring practices is to develop tools, policies and protocols that will facilitate enhanced communication and collaboration.
The foundation for improving communication and collaboration between specialists and referring veterinarians is to build positive relationships. There is a limit to the rapport that can be developed on the phone. Face-to-face meetings are much more productive to achieve long-term, friendly relationships. While it may seem like a daunting task, the value of clinic visitations by specialty practices to referring practices should not be underestimated. All new specialists joining a practice should spend time visiting area hospitals to get to know the referring veterinarians. For established practices, specialists should set up visits to referring practices as needed to meet new veterinarians, to discuss new services they offer, to address specific concerns of the practice and to improve or enhance existing relationships. These visits can be done during slow times to facilitate busy work schedules. An organized, regular schedule of visits to area practices should be established by the specialty practice manager or hospital administrator. Hospitals that have referring veterinarian liaisons may have these individuals or other key personnel assist the administrator with the clinic visits. The value of clinic visitations is maximized if the individuals doing the visits have a clear agenda. For example, aside from developing friendly rapport, these visits should be set up to ask for feedback from area practices regarding the services offered by the specialty practice, to disseminate information regarding any new services, technology or staff, to discuss relevant issues such as timeliness of referrals and to communicate policies or protocols of the specialty practice.
Given that specialty hospitals have a significant number of referring practices and time limitations to do clinic visits, a policy should be in place to encourage referring veterinarians to visit the specialty practice. Specialty practices need to decide if they have an open-door policy for area veterinarians or if they want to set boundaries. Regardless, this protocol then needs to be consistently communicated to referring veterinarians. Specific events such as continuing education seminars, focus groups, rounds, and open-houses are good ways to increase visits by area veterinarians to the specialty practice.
Written Communication Tools
Written communication tools such as mailed letters, faxed memos and newsletters should not be overlooked as a means to keep in touch with referring veterinarians about relevant issues. Although these tools are not a replacement for face-to-face meetings, they can serve as an opportunity to deliver consistent messages and should be utilized to enhance communication. For example, specialty practices could send out a letter to area veterinarians reviewing the importance of receiving complete and relevant medical records in order to provide the best medical care to patients. The letter would outline specifics regarding the format and content for medical records desired by the specialists including encouraging practitioners to use referral forms. As the old saying goes, "You don't get what you don't ask for." Compliance on the part of referring veterinarians may not be perfect but most specialty practices would likely be happy with any improvements in the submission of medical records.
Another example of using written tools to enhance communication would be to include information in the specialty practice newsletter on topics such as timeliness of referrals. Articles written by specialists on various medical topics should always include specifics regarding clinical symptoms or prognosis that affect when a case should be referred.
All specialty practices should leverage the use of their website to communicate with referring veterinarians. Referral forms, articles, case studies, newsletters, referral guidelines, hospital policies and a calendar of continuing education events can all be posted on the website. Specialty practices can also provide links to other web sites that are a credible resource for further information on a variety of medical topics. Another communication tool that can be used via the specialty practice website is posting of surveys to gather feedback from area veterinarians on client service or other issues.
Many specialists report that they would like to communicate more with referring veterinarians via email. This form of communication is particularly desirable since specialists can often copy and paste medical findings from their software into emails to veterinarians. In addition, email allows specialists to respond to practitioners outside of regular working hours. Those specialty practices desiring to increase the usage of email need to begin gathering email addresses from area veterinarians. Many specialty practices already use their existing software to enter relevant information regarding the preferences of area veterinarians and may be able to add email addresses in this area.
Continuing Education for Referring Veterinarians
One of the marketing tools frequently utilized by specialty practices to build relationships with area veterinarians is continuing education seminars. Although attendance at these events can be variable, general practitioners generally report that they find these seminars to be valuable. To maximize the effectiveness of continuing education events, specialty practices need to survey referring veterinarians to determine the preferred time and location for seminars. The advantage of holding seminars at the specialty practice is that this usually involves less cost and affords area veterinarians the opportunity to tour the specialty hospital and meet with multiple hospital personnel. To further increase the value of continuing education events from a marketing perspective, specialty practices should target the topics of the seminar to include information on new services, underutilized services and timeliness of referrals.
In addition to seminars, smaller group meetings such as rounds, study groups and lunch and learns can be very effective for specialists to build relationships with referring veterinarians. These smaller group events allow for more personal interactions and the opportunity to engage in more in-depth dialogue regarding case management.
Referring Veterinarian Liaison
Given the importance of the specialist-referring veterinarian relationship and the large number of referring practices in some communities, it is prudent for specialty practices to designate one or more team members as a referring veterinarian liaison or coordinator. This is often a full-time position in very large hospitals. This staff member is often a technician and should work with the hospital manager and specialists to facilitate improved relationships with area practitioners. Their duties typically include oversight of follow-up referral reports, fielding some phone calls from referring veterinarians, organization of incoming medical records, assisting specialists with follow-up phone calls to area veterinarians, and clinic visitations.
To build positive relationships between specialists and referring veterinarians, efforts should focus on promoting a team approach to veterinary care for pets and enhancing communication between specialty and general practices. When referring veterinarians and specialists work together effectively, opportunities exist to improve the quality of patient care, to enhance pet owner satisfaction and to increase medical service revenues for all practices.