Veterinary Specialisation - the questions answered

In October 2011 The Royal College of Veterinary Surgeons published a working party consultation paper titled - Specialisation in the Veterinary Profession. The document contained 12 questions and requested individuals and interested groups to submit their thoughts; the closing date for reponses was 9th December 2011. What follows are Vet Juris' responses to those 12 questions. The report can be downloaded from the RCVS web site at http://www.rcvs.org.uk/document-library/specialisation-in-the-veterinary-profession/

Question 1.

Overall, do you think these proposals simplify the system and add clarity for the profession and the general public?

Overall, the measures outlined do go some way to simplifying the system for the profession, but not necessarily so for the public. The first point I would make regards the plethora of post nominal letters associated with the certificate qualification. Many members of the public equate the quantity of letters with the quality of the qualification, which can be misleading. But, suggesting that, the listing of the subjects studied on the paper certificate obviates the need for post nominal titles ignores the needs of the primary veterinary surgeon searching, in a directory, for a suitable colleague of whom they may wish to seek a second opinion.

Any suggestion that a particular veterinary surgeon is a Specialist, without clarifying what that speciality is, risks confusing the client. They may know or hear that a particular vet is a specialist – not knowing that the speciality is, for example, in ophthalmology – and seek out their opinion on matters outside of their specialised field. This would be compounded by the suggestion, made on page 19 of the report that implies a practice can be deemed a “Specialist Practice” by virtue of employing someone who has been accredited by the RCVS. A practice should not be able to hold specialist status, only an individual.

Question 2.

Do you have any comments on the principles set out in chapter 3?

The general principles appear to be promoting a reductionist, medical model for veterinary specialisation. In the Ch.3.2 two important phrases are mentioned: bullet point 1. “animal welfare” and bullet point 5. “focus on ethical issues”. These points are unlikely to be adequately addressed by the model proposed. Society’s values have changed considerably since the first implementation the Certificate and Diploma programs; the acceptance of the pet as a member of the family, and pressure-group concerns about how our food is produced. The veterinary profession needs to be seen addressing these issues at the holistic level. The inception of the Diploma in Welfare, Ethics and Law goes some way towards this. However, the profession needs to have a wider discourse with other disciplines in areas, such as, psychology, sociology and ethology. This view was expounded by Dr Viner during the recent debate on Postgraduate Education – published in The Veterinary Record on October 8^th 2011.

Veterinary surgeons are not doctors; they do not have ownership of the diagnosis; that remains with the animal’s owner. Much of the stress in veterinary practice (reflected in the highest suicide rate within the professions) is brought about by the cognitive dissonance of the realities of practice. Gaining the broader perspective, vets can inform, enlighten and educate their clients of the veterinary profession’s social mandate – which is a privilege, and so bring about a better quality of life for the animals in our guardianship. Many of the procedures and interventions currently carried out, which, under the proposed reductionist model, would flourish could be rendered obsolete if vets engaged in this dialogue. The profession needs to take heed of the socio-political climate; especially in the area of animal welfare and ethics before the decision making capacity is taken out of the hands of the profession by Parliament.

Question 3.

Do you agree with the outline in Chapter 4 on the need to simplify the framework for veterinary specialisation?

I agree that chapter 4 needs to be simplified. Half of the chapter could be dispensed with by starting with a single sentence. Certificate holders are not specialist and should not promote themselves, or allow themselves to be promoted, as such, by others.

A number of assumptions are made. In paragraph 7 it is suggested that the mere title of “RCVS Recognised Specialist” removes any need for the client to check or interpret the qualification. How is the client to know if the specialism is the appropriate one for their animal? Without knowing the signalment of the case the choice could be very difficult.

Paragraph 12 assumes that a Recognised Specialist will have significantly more expertise; one does not necessarily follow the other. The statement ignores the art of the science and the value of experience.

Question 4.

Do you agree that there is a need to simplify the range of qualifications titles and post nominal letters that are shown against veterinary surgeons’ names in the RCVS register?

Yes, the post nominal letters need to be simplified yet, remain informative.

Question 5.

Do you agree that specialist status should continue to be pitched at the equivalent of the RCVS Diploma level – level 8 in the national qualifications framework? Do you have any comments on the proposed specialist level descriptor?

I agree that there is a need to define the requirements for specialist status and part of that process is setting the diploma at the appropriate level. However, as this closes one door another, larger door opens. EC Directive 2005/36 Article 13 (Conditions for recognition) 1 (b) “…they shall attest a level of professional qualification at least equivalent to the level immediately prior to that which is required in the host Member State…”

What this means is: if the RCVS sets the level at 8 (PhD), they would have to accept applications from level 7 (Masters) from EU applicants. Similarly, if CertAVP is set at level 7 the College would have to accept level 6 (Hons) EU applicants. However, it is my understanding that the College would be able to insist on the higher qualification for U.K. applications; although, in practice, this would be problematic.

Question 6.

Do you agree with the proposal for an accredited “middle tier” for veterinary surgeons below full Specialist status which would be subject to periodic revalidation? If not, why? If you do agree with the concept of the accredited middle tier, what do you suggest it should be called?

The question falls into the trap that it is trying to abolish; that of confusion between specialist and non-specialist. The question describes Specialists as having “full Specialist status” – implying that Certificate holders would be “semi Specialists”. Certificate holders are NOT specialists – period. This confusion has come about because, in my opinion, the document spends too much time dwelling on Certificates, when Certificates are not the subject of the Consultation.

I fully agree with this idea; the need for revalidation is an essential component, for the reasons outlined in the consultation document. In my view, the titles suggested in the Consultation are unsuitable; “Acknowledged” and “Advanced”  both have antonyms that could, in the client’s eyes, undermine a vet who, other than not having pursued a higher level of veterinary education (for one of any number of reasons) is an excellent and conscientious practitioner. They could be labelled, by default, un-acknowledged or non-advanced. My suggestion would be “Consultant”, it implies a higher level, it does not have a natural antonym and it does reflect the in-house status, in my opinion, of a Certificate holder; that they are often consulted by their work colleagues to give advice or an informal second opinion.

Question 7.

Do you agree that the RCVS should drop the title “RCVS Recognised Specialist” and that specialists should simply be called “veterinary specialists” – or just “specialists”?

Yes, the cumbersome title should be dropped, and I believe the adjective is unnecessary? Doctors that specialise are not labelled “medical specialists”. However, I would suggest that it would be difficult to control the use of the word “veterinary” (other than in its legally defined context of “veterinary surgeon” and its derivations) because it is an adjective. If one tries a thought exercise – what title would be given to an accountant or a lawyer who works, predominantly, within the veterinary sector? Probably, a Chartered Accountant (Veterinary Specialist) and Lawyer (Veterinary Specialist); the College would have no control over these legitimate usages. If the College wants to maintain some legislative control of the specialist title, it would need to attach it to a noun such as “Specialist Veterinarian” or by combining it with the acronym RCVS “RCVS Specialist” – the latter, I think, is more user-friendly. Finally, on this point, I would offer, that the public would be better informed if the area of specialisation was followed in parenthesis – unabbreviated e.g.  RCVS Specialist (Ophthalmology). 

Question 8.

Do you agree that we need to increase the number of accredited specialists as set out in Chapter 6? Do you agree with the interim measures proposed to consider applications via credentials committees assessing evidence against the specialist level descriptor? If not, please outline why?

I do not see the need to follow the reductionist, medical model in veterinary medicine for the reasons cited above. If there is a market demand for more clinical specialists the void will be filled. What, in my opinion, would be a grave mistake would be to create a “false supply” and then try and manipulate the consumer to produce a demand. This could be construed as a “measure” following from the judgment in Commission v Ireland (case 249/81) [1982] ECR 4005 – “even measures that are non-binding and do not emanate directly from government, but which are capable of influencing the conduct of traders and consumers, may be measures”. That is, a measure equivalent to a quantitative restriction (MEQR) and the practice is unlawful.

I do see the need for the veterinary profession to look to other disciplines to develop a strong code of welfare and ethics and to be proactive in meeting the changing demands of a modern society that is, rightly, demanding more rights for the animals and looking to vets to provide some leadership. This challenge can be met by veterinary surgeons developing knowledge and expertise in disciplines that impact upon the practice of veterinary medicine and surgery; a view that was echoed by Stephen May at the first International Conference on Veterinary and Animal Ethics in September 2011.

I have pointed out what, I believe, will be a problem in defining the specialist level descriptor. This is an example where the profession needs to look outwards. The Veterinary Surgeons Act 1966 is half a century old, it does not answer the questions that have been raised in a post 1972 Europe, let alone a post 1998 Europe that is defined by The Human Rights Act and the four basic freedoms viz. the freedom of movement of persons; the freedom of movement of goods; the freedom of movement of capital and the freedom to provide services. With respect, there appears to be no one on the Working Party who is legally literate. There is talk of legislative change but the profession has not caught up with the legislative changes that have already occurred.

That said, I do see the merit in having a credentials committee for admitting onto a Specialists register, veterinary surgeons that have expertise and qualifications in disciplines that are not in the mainstream of the veterinary curriculum and consequently no Diploma course is provided; an example of this would be veterinary forensic medicine.

I am confused by the view of the Working Party that there is little incentive (other than pride in the title) for vets to pursue Specialist status. One is able to perform clinical tasks at a higher level, enhance the lives of the patients in their care, enhance the lives of the animal owning public, contribute to the ethical production of food, earn more, pass one’s knowledge on to others, research and extend the frontiers of veterinary knowledge, become a respected member of a proud profession and a respected member of society. What other incentives are missing from this list?

Question 9.

Do you agree with the suggestion that everyone who is accredited as a specialist should also be awarded the title Fellow (FRCVS)?

Education is its own reward.

Does the working party really believe that mature, intelligent professionals are going to be incentivised to study for a specialist qualification, which they otherwise would have foregone, by virtue of being able to put a different letter on their badge? If so, shouldn’t the motivation and maturity of the candidate be brought into question? I can visualize them now, repeatedly signing their names followed by FRCVS throughout the three years, or more, of their studies.

Additionally, the proposal would, by default, lessen the status of the award that has been earned through the meritorious, and often selfless, effort of the many current, deserving holders of the title “Fellow”. Does the working party feel that the achievement of a PhD (equivalent) merits the veterinary profession’s highest accolade?

Question 10.

Do you have any suggestions as how more veterinary surgeons could be encouraged and supported to work towards the RCVS Fellowship?

Ask them. Reading the literature and noting those who are presenting papers at conferences will identify many likely candidates. Possibly, the RCVS could provide funding or grants for practicing vets to pursue doctoral studies in other disciplines that may have an impact on the provision of ethical, welfare based veterinary medicine and surgery. It is important to look to the market and respond to its needs, what John Adams would call “The Invisible Hand” of free market forces. The veterinary profession is not sophisticated enough to micro manage the market, so it shouldn’t try. If there is a financial incentive to take up specialisation people will do it, if there is not then it is because the public do not want it.

The working party have created a new paradigm by way of the descriptors for both the Certificate and Diploma, but do not look to this new model for the answer to their own question. If the Diploma is equated to PhD – level 8, there is no requirement for the holder of a veterinary degree (Honours equivalent) to do a Masters first; it should not be necessary to use the Certificate as a “stepping stone”. Unencumbered by this unnecessary obstacle, many more potential candidates will be prepared to enrol in the Diploma course. In any case, because of the EU laws in, in relation to the recognition of qualification, as outlined above, EU Member States’ veterinary qualification have the equivalence of  a Masters degree in the UK and should entitle the holders of those degrees to freely enrol in the Diploma course.

Question 11.

Do you agree that vets should have an obligation – which would be introduced through the new Code of Professional Conduct – to explain the referral options to clients, including the different levels of expertise at each level?

Absolutely not: This is, of course, alluding to the cascade of referral. Even if the proposal were legal, it would be morally and ethically untenable.

Let us look at an example. Rover, a 14 year old border collie with a grade 6/6 heart murmur and respiratory rales; mildly anaemic and a medicated diabetic, has been presented with a compound fracture to the right antebrachium. To whom would you refer Rover? The owner is an elderly, retired gentleman of modest means who lives alone with the dog; he does not have insurance.

1. The RCVS Specialist (Orthopaedics) down the road who has a nice practice, with a basic in house laboratory and has nurses monitoring the anaesthetics.
2. The Veterinary Hospital in the next town, that has all bells and whistles (and a machine that goes ping), which is staffed by various CertAVPs.
3. Or you with a good deal of experience in fixing bones over the last 25 years, you have a lab 10 minutes away and a friend, a Cert VA, who has agreed to pop over and give you a hand with the case.

Anyone who answers this question with reference to the cascade is not, in my opinion, fit to be a veterinary surgeon, and needs to go on a course in ethics. What the owner is going to want is a happy dog that is alive, and have some money left over to pay for his winter fuel bills. As Plato said – the fundamental function of a shepherd is to protect and improve the sheep under his aegis; his role as a wage earner is secondary to that mission.

Vets, by and large, do not work within a sophisticated medical infrastructure; and cases do not all present themselves as clear cut single organ system problems. The orthopaedic surgeons will not necessarily have an oncology, internal medicine or anaesthetic specialist along the corridor who can pop his/her head around the door and have a quick look at a case for them, that has turned out not to be so clear cut as was first thought. These are the considerations primary vets have to take into account when coming to the decision – to whom do I refer? Vets do not, or at least, should not be reducing the patients in their care to the animal’s condition (the fractured leg in the bottom kennel) vets treat “whole animals” to which is owed the primary responsibility; the secondary responsibility is to the owner.

There are, also, the not so nice realities of competitive, medical model driven practice. The referral centre, that insists on repeating all of the primary vet’s radiology and laboratory work. Or the centre that has the client continually return for pointless, repeat examinations; at one such centre the assistant told the owner to make the appointment and cancel it once she has gotten home, otherwise he would get in trouble with the boss. Should these considerations be presented to the client, enabling them to reach an informed decision? Would the primary vet be transgressing the professional code of etiquette, by talking disparagingly of another vet? – bringing the profession into disrepute.

An informed decision cannot be made without all of the salient facts that would influence that decision (unlike a professional decision). It would be against the “rules” to give the client all the facts that the primary vet would have to weigh up; yet you propose holding the primary vet accountable for not raising these issues with the client.

Veterinary surgeons hold Aesclepian authority; clients, on the whole, want vets to exercise this authority, on their behalf, in a legal, ethical, moral way to enhance the health and welfare of their pet or animals in their care. Professional healers are trusted to make the right decisions for the right reasons. Certainly, if asked to justify one’s decision, as a professional one would/should feel obliged to do so – ethics come before etiquette.

This discussion is, as I have implied, hypothetical; the proposal is completely illegal. Articles 49 (Establishment) and 56 (Services) of The Treaty on the Functioning of the European Union, prohibits restrictions on the freedom of establishment or the freedom to provide services. The case law definition of a restriction can be found in Procureur du Roi v Dassonville (case 8/74) [1974] ECR 837 “rules enacted by a Member State which are capable of hindering directly or indirectly, actually or potentially, intra-Community trade.” - The rule has no de minimis; the merest hindrance is illegal.

The case law was further developed in both Gebhard and Alpine Investments. Any derogation to these rules must be: non discriminatory, an imperative requirement, suitable for the attainment of the objective and proportionate. Even if the proposals were to circumvent these obstacles, they would come up against the secondary legislation in the form of Directive 2006/123/EC (commonly known by the title Services Directive).

Question 12.

If you wish to comment on any relevant issue that is not covered by the above questions, please do so.

It seems that the objective of this Consultation is to increase the number of veterinary specialists that are in practice. This raises the question of why?

The stated aims are “first class animal welfare”, “improving treatment”, “developing new methods of treatment” and the “pursuit of research”. How does the first of these aims relate to the other three? Pain and suffering in the higher mammals have a similar neurophysiologic basis; however, we know very little, if anything, about the emotional component of pain in animals. Who on the Working Party is prepared to hypothesise on the perceived nature of pain when, as in veterinary patients, the resolution of that pain cannot be anticipated? Therefore, does the provision of critical care over a period of weeks or months, for example, for a severely scalded animal necessarily equate with “first class animal welfare”?

The “pursuit of research” conflicts with the primacy of the maxim primum non nocere. Abuses would be difficult to identify or safeguard against. Veterinary surgeons would be in danger of treating their charges as experiments – prolonging treatments for their own benefits – extracting as much data from the case as possible, rather than acting for the benefit of their patient. This risk is far greater in the clinical environment than in the research institutes, where society has demanded limits and Parliament has legislated, introducing end-points that minimise pain and suffering - The Animals (Scientific Procedures) Act 1986.

How can the proposals give clients “access to the highest level of expertise for every case”? The example illustrated in my response to question 11 shows the near impossibility of this aim. There are of course some excellent multidisciplinary specialist veterinary hospitals The Willows, Davies and of course the Veterinary Universities. But, without wanting to denigrate in any way, others such as Cave and Fitzpatrick do not have multidisciplinary hospitals; the two latter do not even have to my knowledge, specialist anaesthetists. This situation seems unlikely to change in the very near future; according to the figures supplied in appendix 2 there are, currently, only 11 RCVS Recognised Specialists in anaesthesia registered, out of the total of 71 who have been awarded the Diploma Access to these centres is, in any case, always going to be dependent on the clients having the financial means (even if that means being able to afford the insurance premiums) to use them. So, at best, these proposals would create a two tier veterinary service.

The sentiment contained in Chapter 5. paragraph 2. is, I believe, a more realistic goal – “the animal owning public needs to be able to access this level of expertise for the more complex and unusual cases”.

The disparity between the numbers of RCVS Diplomats, in all disciplines, and those registered with the RCVS would benefit from some scrutiny. Obviously, natural attrition, through death and retirement would account for some, but, for example, how many potential Specialist anaesthetists are there? Two questions would arise from this exercise: Why are the Diplomats not registering as such? And, what is the status of these non-registered Specialists?

The immediate benefit of Diplomats being registered is that the relevant expertise would be more readily accessible to the primary vet, and others, and therefore, available to the patient. It would also give the Working Party the appropriate figures with which to make any projected assumptions. The second question is on the status of the Diplomats: Does the RCVS intend to recognise as Specialist only those who have registered, or, does the qualification, subject to revalidation, “speak for itself”?

The RCVS should engage a professional marketing company to conduct a national survey to find out what society wants and expects from a 21^st century veterinary profession. I would be surprised if there was shown to be a demand for increased specialisation and consequent heroic treatments. If the demand is there, individuals within the profession will respond. People respond to potential rewards, this is the most fundamental rule of economics. Whatever they are, incentives make people work harder. And, quite frankly, allowing someone to change one letter in his or her post nominal is not an incentive, except for the most shallow amongst us.

The Working Party is clearly trying to encourage veterinary surgeons to qualify as specialist on the promise of a revenue stream that is to be disguised as a “professional duty” to refer, in preference, by way of a cascade to “Veterinary Specialists”. Nick Henderson – founder member of the BSAVA – voices this view in The Veterinary Times Vol. 41 No. 44, with his cynical cry “So, we have the supply – the question is how big can we make the demand?” A modern veterinary profession does not need his kind. This proposed manipulation of the market is wrong economically, legally, morally and ethically.

The first step in encouraging vets to pursue higher qualifications would be to instil a culture of lifelong learning into the profession. The current requirement of 35 hours per year CPD is, I believe, wholly inadequate; as a musician playing bass guitar; I would practice more than 35 hours a month just to keep my hands and eyes in. I would consider 100 hours CPD per year as a minimum – so long as it was structured and verifiable study; it cannot be considered sufficient to merely report having read some magazines.

The next step would be to remove the barrier of having to complete a Certificate before embarking on a Diploma study. Also, foster alternative routes to specialisation via PhDs through the awarding of RCVS grants and awards.

Titles are the least of the problem. If the specialism is clinical: RCVS Specialist (speciality); if non clinical just: RCVS Specialist. Alternatively, the Diploma title could be: Consultant and that for Certificate holders could be: Certified.

In conclusion, whilst I am sure that the intentions of the Royal College of Veterinary Surgeons and the work conducted on their behest by the Working Party has honourable intentions, I feel that the lack of breadth in the Working Party and the adoption of a model that is inconsistent with the ethical creed of the veterinary profession, has resulted in a document that does not take the profession forward. It is an impossible task to intellectually separate the profession from societal needs and expectations, economic reality and the rule of law and expect to get a workable model of specialisation.

VJ ©2011