A contractor doing work on my house called me on Sunday after spending Saturday night at the emergency vet clinic. The previous day, his dog ate a bag of rawhide treats and then, inhibitions thrown to the wind, a bunch of other stuff. He began retching and vomiting shortly thereafter.
At the emergency clinic, radiographs were taken and an oddly shaped item in the stomach was visible. Looking at this guy’s cell phone, I suspected it was a bag of some sort, but it was impossible to be sure. The contractor was told the emergency clinic could try endoscopy for $6,000 or do an exploratory surgery for $9,000. He was also told that if they tried endoscopy and it didn’t work, there would be no discount on the foreign body surgery that would then be required. That’s right… He was possibly looking at $15,000!
This guy simply didn’t have $6,000 to gamble on the endoscopy skills of a veterinarian he just met, and definitely didn’t have $15,000 if the endoscope came up short. He brought his dog home and was calling me first thing in the morning for advice. I sent him to the one general practice I know to be open on Sunday and prayed that there was a vet there willing and able to cut a foreign body. I haven’t heard what happened yet.
When I hung up the phone, all I could think was “$15,000 for a foreign body?!” Even on emergency, that’s hard to get my head around. I remember when we just took those straight to surgery for somewhere between $1,500 and $2,500. It was only about 10 years ago.
2 Kinds of Affordable
One of my biggest pet peeves when people talk about keeping care affordable is how all veterinary care is lumped into one problem bucket. It’s not one problem. There are two very distinctly different challenges when it comes to keeping care affordable. The first is keeping basic wellness care affordable. This is helping people get vaccines, flea medicines, treatments for ear and skin infections, etc. This is a battle to help people afford services that generally cost $100-$500 dollars.
When you hear corporations talk about how they have big plans to make care affordable, this is the type of care they are talking about. This is the trojan horse meant to get regulations changed so they can sell medications directly to consumers or have people who are not veterinarians (and thus much cheaper to hire) treating patients without direct veterinarian supervision.
The second category of affordability problems is entirely different and involves helping pet owners pay for services that require intensive veterinarian time and skill. The challenge of helping someone get the flea medicine their pet desperately needs is nothing compared to helping them get the orthopedic surgery their cat who was just hit by a car requires. This type of affordability problem deals with the expense of surgical intervention, hospitalization, or intensive outpatient care, especially when emergency or specialty clinics are involved.
Dutch selling apoquel to pet owners without doing a physical examination is doing nothing to help people who have legitimately sick pets requiring aggressive medical intervention. These are the cases where pets would live if they got decisive care, but are put to sleep because the pet owner can’t afford a referral to the specialty hospital. This is the real access to care problem that hits veterinary professionals in the gut day after day.
The groups clamoring to “help” the access to care problems are almost uniformly focused on making wellness care more affordable. In reality, they are making intensive care more expensive by stripping away the “low hanging fruit” profit centers that veterinarians have always used to subsidize procedures like surgeries and dentistries. Success by these groups is only going to make economic euthanasia more common.
As the cost of specialty and emergency care continues to rise sharply, the gap between what it costs to provide wellness care and what it costs to fix broken pets is getting bigger. I heard someone joke recently that it costs $6,000 to touch the doorknob at a well-known chain of specialty hospitals. Most pet owners don’t have this.
The Only Option for Saving Lives
As the cost of specialty and emergency care rises, and veterinary practices continue to come under assault from outside companies wanting to take the most profitable parts of the profession and leave the broken animals for others to deal with, we only have one viable option that I see. General practice (GP) veterinarians must step into the space between routine medicine and specialty care.
At a recent conference, I spoke with two different GP veterinarians who have successfully performed Patent Ductus Arteriosus (PDA) surgeries on puppies. For those unfamiliar, this is heart surgery to close a blood vessel that fails to close after birth, connecting the aorta and pulmonary artery. Can you guess how old these veterinarians are?
If you guessed “in their 60s,” you are correct. It wasn’t that long ago when specialty hospitals didn’t exist and general practices either made their best attempt at a complex procedure or the animal died. Since that time, specialty care has become much more geographically available, so the theoretical ability to send patients away has greatly increased. More importantly, the idea that veterinary schools should function as specialty hospitals and teaching should be overwhelmingly provided by specialists has also become the norm.
The outcome of these changes is that few veterinarians are now working so far from a specialty hospital that they can’t refer and many have been indoctrinated with the idea that complex cases require specialty care. In a world where specialty care is affordable for most people, maybe there is nothing wrong with this idea. After all, it’s the model human medicine is firmly built on.
The problem is that, when specialty care costs 5-figures and very few families have pet insurance, the geography of the specialty clinics doesn’t matter. You can live next door to a specialty hospital, but if you don’t have $6,000, that clinic might as well be in another country.
Increasingly, we are seeing scenarios where a GP can step up and try, or the pet can be put to sleep because referral care is not going to happen. I mentioned earlier the two GPs I talked to who performed PDA surgeries. They were both terrified when they did it. They were both reading from a text book in the surgery suite, and both puppies lived to be over 15 years of age.
There are maverick veterinarians out there right now, and they are not all older vets. You probably know one of them. Some of them are working in places where referral care is not an option. Others are just down the road cutting GDVs, pyometras, and all sorts of simple orthopedic surgeries because that’s what they feel needs to happen. They are male, female, or nonbinary. They are older, or younger. Some are extremely experienced and some in their first year of practice. They are hospitalizing patients and handling internal medicine cases. And because they are in general practice, they are providing these services at a significantly lower cost than specialty hospitals and also making a good living doing it.
But we will get sued!
There seems to be great fear that if veterinarians do medical work they have not been explicitly trained for, they are at risk of legal action. This risk is minimal. We must maintain good medical records (and thanks to AI scribes, our records have probably never been better). We must recommend referral and be clear that specialty care is superior to the care our general practices can provide. We must be clear about our training and experience (or lack thereof), and tell our clients that we might not be successful and that euthanasia may become our only option. We must document all of this.
And then, we need more GPs who will go for it.
This Is Our Future
I do not know what is going to happen in veterinary medicine in the next 10 years, but I strongly suspect more and more wellness care will move out of the hands of veterinarians. I am certain the costs of emergency and specialty care will continue to increase, and I think AI will do more and more inside our practices. If these things come to pass, what will be left for veterinarians?
The answer is exactly what I am proposing.
AI will not perform GDV surgeries or do resection-anastomosis procedures (during our careers, anyway), midlevel practitioners will not treat the IMHA dog, and the average pet owner will not find specialty care more affordable 5 years from now. For the sake of our patients, we need maverick GPs who, when pet owners cannot afford referral, are willing to give pet owners another option besides euthanasia.
Pets need veterinarians to be bold. Families need them to continuously improve their knowledge and skills. Practices need them to communicate clearly, document thoroughly, and then step into the fray. Finally, future doctors need veterinary schools to equip them with the skills, knowledge, and confidence they need to thrive and serve in the coming decades. Those we serve are depending on us.
