Meet Ralphie, a young boxer (~ 4 years old) with persistent GI signs including vomiting, a poor appetite and weight loss (a pretty standard presentation in Internal Medicine!) An intestinal mass was identified on abdominal ultrasound and he was referred to the surgery service at a local multi speciality facility. Abdominal surgery was fairly routine, he recovered uneventfully and was discharged to home. 

Somewhere along the way, the biopsy interpretation was “missed” by several other services and no specific diagnosis or treatment plan was made. Ralphie continued to have GI signs including a poor appetite, more weight loss and wicked diarrhea. The family veterinarian very diligently pieced together the parts and called me for a consultation. Together we developed a treatment plan and I was able to “weigh in” through clinical updates and lab work from her. Today Ralphie is the best he’s been in years and the family is so thankful!

Guess what his diagnosis was? Yep, the dreaded Inflammatory Bowel Disease…

His story is a little different, in that IBD does not usually present as a focal, solitary lesion. But here we are! Inflammatory Bowel Disease is actually a subset of a noninfectious inflammatory chronic enteropathy. Say what? Unless we have a biopsy to determine the cellular infiltrate, we should try to label all these vague GI cases as having a chronic enteropathy, which can mean several different things. This is a very interesting area for research in both dogs and cats and there are new developments frequently, particularly around the gut microbiome and its relationship to the immune system.

For Ralphie, we started at the beginning and reviewed his history, other findings and histopathology report, which did define lymphoplasmacytic inflammatory bowel disease. An immunosuppressive course of steroid was initiated along with azathioprine and a novel protein diet. Over the next several months he made tangible improvements in his stool quality, body weight and condition and eventually transitioned off all his medications and now he is living his best life!

Let’s take a minute to read between the lines in this story.

What is the difference between a referral and a consultation?

Think of a referral as transferring the case to someone else moving forward. This would mean specialized diagnostics, prolonged hospitalization, difficult conversations, lots of rechecks and treatment plan adjustments with the specialist.

Think of a consultation as the ‘ole phone-a-friend option (or text these days…). This would mean something very similar to what VetHive means to us all, which is advice or recommendations (sometimes very specific, sometimes more broad) on a case – but you remain in charge. So most conversations, additional diagnostics, rechecks and treatment plan adjustments go through you – not the specialist.

How do I know which one I want?

A referral is best when the case really should be served by folks with advanced training, tools and resources.

Consultations, however, are ever-increasing and have a huge purpose to serve! Basically, I think of a consultation as helping to make you – the family veterinarian – look amazing while serving this pet and their family! This is most effective when a pet is determined to have a stable condition that may require more testing or treatment.

What is most helpful to me and the specialist when consulting on a case?

1. Ensure an understanding of the distinction between a case referral and consultation relationship
2. Ensure the pet owner understands why another doctor is being requested for their pet’s care
3. Ensure optimal patient preparation using anxiolytics and low stress or Fear Free patient handling (specifically if a mobile specialist is available, but it’s also great patient care)
4. Ensure a maximal case management experience by providing current, relevant medical records, imaging, communications. We will often receive pages of medication refills, itemized billing and vaccination history instead.
5. Ensure a thorough understanding of the specialist’s recommendations to clearly and confidently explain back to the pet owner
6. Practice active and mindful listening (all parties) to ensure optimal patient care
7. Ensure workflow after the consultation is completed that locates the written report(s) and alerts the requesting doctor
8. Discuss reasonable expectations about long term follow up on a single case, i.e., updates, more questions or lab results within a few weeks (but not months or more later)

#practicepearls

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 About the Author: Jessica Larson, DVM, DACVIM (SAIM)

Dr. Jessica Larson started her career in private specialty practice, where she stayed for many years. She then transitioned to an industry role for a few years as a professional services veterinarian working to launch exciting therapeutics. Currently, she is in a mobile specialty practice where she literally walks in the back door of many vet hospitals and jumps in to help!

 

#practicepearls