HOD requests spectrum of care resources
The AVMA House of Delegates (HOD) featured spectrum of care as a topic of discussion during its Veterinary Information Forum (VIF), which took place on July 13 as part of the regular annual session of the HOD, held in Denver in conjunction with AVMA Convention 2023.
The description "spectrum of care" is relatively new, but the concept is not. Definitions vary, but essentially it means empowering veterinarians and clients to consider a wide range of treatment options. At one end is basic, less resource-dependent, lower-cost, and usually less-invasive and lower-tech care. At the other end is advanced, more resource-dependent, higher-cost, and often more-invasive and higher-tech care.
Between the ends of the spectrum, many choices exist. By offering a variety of care options that are responsive to client beliefs, values, financial considerations, and expectations, veterinary health care providers can help increase accessibility of veterinary care and client compliance.
On the recommendation of the reference committee to which the VIF topic was assigned, delegates voted to refer the topic to the AVMA Board of Directors (BOD) and asked that they consider further investigation, collaboration with stakeholders, scoping potential research needs, developing policy, and creating a spectrum of care toolkit.
Potential resources in the spectrum of care toolkit could include guidance documents and continuing education—derived from existing resources or created as new ones—with an emphasis on effective communication with clients and appropriate documentation in the medical records.
The recommendation also stated that collaborating partners should include, but may not be limited to, the AVMA, including the AVMA Trusts; state VMAs; the American Association of Veterinary State Boards (AAVSB); and the American Association of Veterinary Medical Colleges (AAVMC), and that this effort could take the form of a task force.
The House requested that an update be provided at the 2024 HOD winter session in January in Chicago.
Client communication and recordkeeping
Research backs up the idea that how veterinarians talk with clients can impact clients' involvement in the decision-making process as well as their satisfaction. Results from study published in PLoS One in February 2021 suggest that "pet owners expect to be supported by their veterinarian to make informed decisions by understanding the client's current knowledge, tailoring information and educating clients about their options.
"Breakdowns in the information exchange process can impact pet owners' perceptions of veterinarians' motivations. Pet owners' emphasis on partnership suggests that a collaborative approach between veterinarians and clients may improve client satisfaction."
Dr. Joe Ed Conn, alternate delegate for Tennessee, said one barrier to client communication is time.
"We're all short of time. My 20-minute appointment may mean I'm in the exam room for five minutes," he said. "It's hard to present a lot of options to the point that they can make a legitimate decision in five minutes."
Dr. Lauren Atkins, delegate for Maryland, suggested this is where leveraging veterinary technicians fully can come into play. "Get your good communicators to help with that," she said.
Dr. Gary Stuer, delegate for the American Holistic Veterinary Medical Association, lives in rural western Maine. He recently hired a new graduate after searching for three years and says he felt it was important to talk to candidates about this issue because many of his clients aren't financially able or willing to drive to referral practices for procedures.
"One of the most important things we do as veterinarians with clients is to communicate and have open discussions with them," Dr. Stuer said. "We need to do same with new associates, especially new graduates."
He has made a list of 40 things he commonly sees in the clinic and plans to review with his new employee how to offer a spectrum of care in each scenario.
Dr. Jane Barlow Roy, delegate for New Hampshire, pointed out that while many of the discussions around spectrum of care have to do with financial concerns, at the other end of the spectrum, in more affluent communities, is the issue of futile care.
"There are clients asking us to do what we may feel is unrealistic with unrealistic expectations," she said. "There may be a poor outcome but the client wants to keep going."
Whatever end of the spectrum, Dr. Roy emphasized the importance of client communication and documentation.
"Most (veterinary licensing) boards, I have heard, when a case doesn't go well it is because of poor communication between a client and the veterinarian. Then (the veterinarian) gets dinged for poor documentation. And that's what I try to instill in the people I talk to: Make sure you're clear and concise with your recommendations and then follow up that up with proper documentation about what they choose."
Dr. Hunter Lang, delegate for the American Association of Bovine Practitioners (AABP), echoed Dr. Roy's sentiments. As chair of his state's veterinary board, Dr. Lang said complaints filed against practitioners have doubled in the past three years—the majority of which arise from poor communication and documentation.
"Communication is critical and examining boards try to weigh the veterinarian and consumer side, and I think we do a good job in general," he said.
Dr. Gary Stuer, delegate to American Holistic Veterinary Medical Association, says one of the most important things veterinarians have with clients is the ability to have open discussions with them. He encouraged practitioners to do the same with their associates, especially recent graduates and early career veterinarians (Video by Matt Zinagle)
Veterinary education
Other organizations are also looking at advancing the spectrum of care concept in the profession. The American Association of Veterinary Medical Colleges (AAVMC) established its Spectrum of Care Initiative (SOCI) in 2021 with support from The Stanton Foundation. This initiative is developing strategies and infrastructure for veterinary educators to prepare graduates to practice across the spectrum.
Dr. Liesa Stone, delegate for Ohio, shared that The Ohio State University (OSU) is an early adopter of teaching spectrum of care. OSU's College of Veterinary Medicine is rolling out a new curriculum in which the concept has been integrated throughout.
"The goal is to instill confidence and competence in our graduates so that when they graduate, they are Day One ready and more comfortable to have those conversations across the spectrum," she said.
Many students come to veterinary school with the perspective that they want to practice the "gold standard" of veterinary medicine, said Dr. Peter Hellyer, delegate for Colorado.
"They fear being incompetent and want to do the right thing. I don't think schools will fix that problem. We can lay the groundwork, but when they come out, they want to do the best (medicine) ever, and they might need a few years' experience to work that out."
Dr. Richard Williams, delegate for Florida, said that it may not come as naturally to students because technology has developed so much in just a few decades.
"Before, there wasn't a lot of great technology. You just treated your patient as best you could do. Now there's these other options where you can get an MRI or CT scan," he said. "Technology will continue to advance and the spectrum of care will continue to get wider and wider."
Regardless of the barriers, delegates acknowledged the importance of continuing a tradition of working with clients to meet their needs. Dr. Kaitlyn Boatright, alternate delegate for Pennsylvania, pointed out that the Royal College of Veterinary Surgeons (RCVS) published an article in September 2022 on a similar concept called contextualized care. This article acknowledges not only financial factors, but also other factors that can impact care, including a client's age, housing situation, disabilities, and more.
"As vets, we have an ability to deal with diverse cases thanks to the advances in science, however, we also need to balance this with an understanding of the additional patient and care givers/owners' factors surrounding a case. Bringing care givers/owners into the decision-making process around treatment can help ensure the outcome for the animal is the best one for them in their circumstances."
A version of this story appears in the September 2023 print issue of JAVMA