Contextualised care in referral practice

Mark Morton:

Hi everybody, welcome to the latest episode of the RCVS Knowledge contextualised care podcast. I’m Mark Morton. I’m the clinical lead for registries at RCVS Knowledge and I’m an orthopedic specialist. Today we’re going to be exploring contextualised care in referral practice. To be clear, we’re not going discuss whether referrals are appropriate or when they are appropriate.

What we’re going to explore today is how we tailor care once a patient is in the referral setting. With specialist expertise and the advanced tests and treatments we have available now, how do we decide which of those things will make a meaningful difference to each patient we see and their owner? Fortunately, you won’t just be hearing from me today. I’m delighted to be joined by two great guests, Lucy Goodwin and Stein Niesen. Welcome to you both. I don’t know if you both want to briefly introduce yourselves, Lucy.

Lucie Goodwin:

Yeah, thank you Mark. My name is Lucy Goodwin. I’m a diplomat of the American College of Veterinary and Telemedicine, having gained my diploma back in 2011. I’ve got a bit of a varied background. worked in primary care practice and referral private practice, as well as doing some charity work, education, academia, and a stint as a clinical pathologist.

My current role is I’m the National Referral Lead for Medicine for Inspiring Vet Care in the UK. My role is sort of part-time clinical, so I work up, get my clinical fix at Blaise Vets Specialists up in Longbridge, but I also support the referral hospitals clinical leadership teams as well as supporting Inspiring Vet Care in developing the strategy within the referral network in the UK.

Mark Morton:

Great, thanks Lucy and Stein.

Stijn Niessen:

Yes, my name is Stein Niessen. I guess I’m a I’m a clinician, I’m an educator and a researcher in in short. Most people know me from my association with the Royal Veterinary College, where I’m still a professor in small animal internal medicine, but I’m also active as an independent internist, heading our own institute, independent institute for independent veterinary specialists. and one of the things that people know me most for is probably the research and advances in endocrinology. one thing that I would like to be more known for is my passion for measuring quality of life, which I think will integrate with what we’re talking about today, because for me that’s the ultimate outcome that will be judged upon. so, I always find it quite silly that actually we don’t have heavy emphasis on that outcome in our studies, research, education, but also in our clinics. So that’s me in a nutshell.

Mark Morton:

Great, thanks, Stein. Yeah, looking at outcomes, of speaking to my own heart there, that’s something I’m passionate about as well. And let’s hope we can get around to touching on that later in the podcast. This might be the longest recorded conversation ever between two internal medics and an orthopedic surgeon, but let’s see how we get on. So, Lucy, let’s start by sort of exploring what does contextualised care look like for you in your referral service, in your referral setting?

Lucie Goodwin:

Yeah, I think it’s the same for us or for me as for any other vet, know, we’ve all got the client and the patient in front of us, regardless of what our role is within veterinary medicine, we’re all sort of doing or trying to do our best to the patient. So, for me, is, we could go with the definition, it’s providing the most appropriate care for that patient and that owner in that set of circumstances. And so it will be very much talking to the pet owner, understanding why they’ve come to see me that day, sort of trying to understand what their desires and wishes are at the end of the process of having their pet referred and then trying to find a plan that’s tailored into what suits them and their pet and what they’re able to do, sort of what can fit in with any logistical challenges that they have. So essentially, it is providing the most appropriate care for that patient at that time in that setting.

Mark Morton:

Great, yeah, I absolutely agree with that. And Stein, similar question to you, really, you’d add to that?

Stijn Niessen:

Yeah, no, I agree with that and I guess I would add to that in that I always think we get the best results when the primary care clinician keeps in touch and keeps working with the specialist team or the specialist that is attending to that patient as well. because as specialists we took the easy route, right? we said we don’t want to know everything about everything. we’re just going to go into the depth of a very narrow area in veterinary medicine.

And that’s what we, you know, are quite comfortable with and in, and therefore we can stay up to date with that very narrow area. and putting that into the contextualised care discussion that enables you to then get to know that owner just like the primary care clinician has done in the best possible way but then take them through a conversation that is loaded with that deep knowledge and deep experience.

And have them hopefully come to a conclusion in terms of diagnostic plan or treatment that fits that particular pet owner combination. But always that should be in that triangle of the primary care clinician being involved in that process as well. And I think communication between referral and referring party is essential there as well, because otherwise, you know, you can get into trouble. And I think we all have been in situations where that communication wasn’t there. And that makes it very difficult to get an outcome that everyone can be satisfied with. So, yeah, to me, same answer as Lucy. Actually, we all should be practicing contextualized care. Maybe the gadgets or the type of procedures are slightly different for a specialist, but the conversations are very much the same. Maybe.

We mentioned percentages in success a little bit more accurately according to the latest study in that very narrow field that either one of us have chosen to specialise in. but the type of conversation is very, very similar.

Mark Morton:

Yeah, that link with primary care vets, I think it is key. I, in orthopaedic, see cases for a very short period of time from trauma or an injury. I know you all both have more chronic patients, but it’s often those primary care vets that have that long standing relationship with owners. And we sort of tend to drop in for short periods of time in that patient’s journey. One of the things that the RCVS knowledge roadmap around contextualised care sort of brought to the fore and tried to nudge us to move away from is this concept of a gold standard. Now, it’s terminology that we all use, and owners recognise and can relate to, but Stein, how do you think we can move away from that idea of a gold standard and move more towards an explanation to owners of the most suitable care?

Stijn Niessen:

Yeah, yeah, no, that’s it’s a really good question and in a way I although we moved away from gold standard and I think we’ve got a movement now that everyone sort of realises that that’s not a helpful terminology. I also think that we shouldn’t just put everything down to contextualised care as such. you can have loads of different words to describe your preferred type of care, as long as it does the job.

You know, and sometimes the right contextualised care option is the gold standard care as we assumed it to be in the past. You know, the one that is described at a conference for internal medics or orthopedics as the latest that gets the best outcome in the highest percentage of cases. Maybe sometimes that is the contextualized care preferred option you end up deciding for together with the owner and the primary care vet.

For me, those words almost are too restrictive. And the one scenario I always highlight with contextualized care discussions is also that when people say, Well, actually we don’t have budgets for all these options, so my contextualized care approach is to go for this option that the owner can afford. But what if that contextualised care option is just not good enough? You know, if that causes intolerable harm or suffering to the animal, then then this clinician might be thinking, well, I act according to the context because there is a limited budget. But still, I’m not feeling good about doing this in the first place. And therefore, depending on our own interpretation of what contextualized care is, and it should be more than just based on finances, different people end up with different explanations or choices for different scenarios. And this is where I guess I got in it very quickly in the introduction. To me, at the end of the day, it’s about the outcome. And is that going to be satisfactory for everyone involved? And that’s including the owner, including the animal, but also the clinicians. have I acted according to my values? which are is very important for all of us, otherwise we won’t last long in this profession.

Stijn Niessen:

And therefore, we need to measure that outcome or at least know what we’re aiming for in the first place. And whatever gets you there, given the circumstances that you’ve got, that’s the right type of care. but therefore, yeah, any I still have difficulties when we start to typify the type of care that we prefer to perform if we don’t do it in the context of the outcome that we’re aiming for and that we’re trying to actually measure the outcome like we measure other stuff. You know, we’re scientists, so we measure all kinds of stuff, but the most important bit we often fail to measure, which is quality of life or impact of treatment.

Mark Morton:

Yeah, absolutely. And I mean, some of the work I’ve done with the, the cruise ship registry and things is an aims exactly around that to look at outcomes, because I don’t think you can talk to owners about treatment options without being able to tell them what the likelihood of a good or poor outcome is with the options that you’re presenting to them. Just to sort of wrap up this sort of introduction to sort of contextualised care. One of the other things that the roadmap picked up on from surveys of people in the veterinary profession, was the barriers to practicing contextualised care. Lucy, do you have any thoughts on particular barriers that we may see in a referral setting as referral clinicians?

Lucie Goodwin:

Yeah, I think there’s lots of them, thank you. And actually, the term gold standard is a barrier. So just going back to what Stein just said, I hate the term because I actually don’t think it really applies to a clinical context. know, it’s the goals, we’re using something that’s done for laboratory-based tests as a gold, you know, comparing one test against another as a gold standard. You can’t really apply that in a clinical scenario in a patient with core morbidities with other things going on in the home and in the owner’s perspective. So, I think that term really doesn’t suit us. And I think in upholding the term gold standard actually can act as a barrier because it puts us into a mindset of this is the only level of care, I can offer and anything other than this gold standard care is substandard or it’s bronze, but what about the platinum standard? What about the platinum plus? You know, it’s all…It’s all just words we’re using that actually is in and of itself putting a barrier into the care that we can offer our patients. So, I think that’s one of the barriers that we can see. I think another barrier that we may see more in referrals is actually how specialists get trained. We train people through residency programs to know everything, know the…that the most advanced treatment options, what, you know, we have to know that have the depth of knowledge to be always offer this highest level of care to the nth degree. We sit exams where we have to demonstrate that knowledge to the nth degree of how we would manage the case in the ideal setting. But at no point are we asking people, but what about the client that…wouldn’t manage to give those drugs because they’ve got arthritis in their hands. So, what alternative have they got to giving these meds to their pet? And I think we take them out of this setting where we’ve had to learn all of this information. put them in a new scenario where that then all needs to be contextualized to the case that’s in front of you. I certainly, for me, there was a bit of a de-learning process coming out of residency where it was like, actually, I can’t do this for all of my clients. I do need to change how I practice.

And I need to be okay with that. I need to be able to get rid of that perfectionism or that desire to only offer this one treatment, which is the best treatment. And actually, that’s not serving all of my clients. If I can only offer them the best, what happens if they can’t have whatever I perceive to be the best? It might not be the right thing for their patients. So, I think there are barriers that we put in place.

By training specialists, so for some that it does take a bit of time to come back from. I certainly, I won’t speak for everybody because we’re all different, but I recognized it in myself and I do see it in some of the people that I trained or who are fresh out of residency where they are sort of struggling is maybe the wrong word, but having to sort of relearn that and find that middle ground. So, I think that can be a bit of a barrier for us.

And then finally, I guess the other thing that can sometimes happen is people are like, but if you’ve been referred to a specialist or you’ve been referred to a clinician for more advanced treatment, is that an expectation that the vet has from you and the owner has from you of offering that level? And so, we automatically go in there without actually again, asking the client, asking the referring vet, know, what was the driving factor here?

Or saying to an owner, why did you come in to see me today? What is it that you want? How far do you want to go? Do you think you’re here for lots of scans? What is it that you actually want to get out of your appointment with us? So, I think that’s an additional barrier that we put in place is that expectation that we have to deliver some very, very advanced treatments.

When actually if we just get to the root of it, speak to our clients and are on our referring vet, find and build that relationship and then we can sort of figure out what is the right thing for those, for that individual pet in the circumstances. So, lots of barriers can be there, but they certainly are, we can overcome them.

Stijn Niessen:

Yeah, and Lucy, because you and I have sat in rounds in multidisciplinary hospital setting, right? and this is the type of learning environment that a specialist has. And what you often see is that then a case is being presented by a specialist in the making, and then others start picking holes in it, right? Have you done this? Have you done that? Have you done this? Have you done that? And actually, that creates an a feeling that that you’re missing things, you’re not doing enough. And I think I agree with you that in our training, there is therefore a possible end outcome where you create initially young specialists that are fearful of not doing something. And it actually takes some experience and confidence and growing up as a specialist to then start dropping tests.

Because you start to evaluate a sense of what is likely going to change the actual management of a case. That’s very difficult for a young specialist to do because they feel vulnerable, that they might be called out by the referring vet, by the client, or by colleagues, since most learning environments, especially in the specialist level, are still not learning environments that are safe enough to actually have these conversations, unfortunately. There’s work being done luckily. Yeah, look luckily, but you know it comes from you know a perfectionist sort of environment that that breeds certain characteristics of the specialist that that you then need to outgrow in the future and now I actually take pride in doing minimalistic approaches and I really enjoy them.

And that’s what I’m trying to teach vets in general, but also fellow specialists as well. That’s really the added advantage of a specialist to be able to pinpoint what is really going to change your view of the case and therefore impact also what you’re going to recommend or do in that case as well. So, yeah, there is something in the education of us specialists that initially might have some negative effects in the type of specialist that you create.

Mark Morton:

I think there’s a sort of this for me links a little bit back to one of the themes that we talked about very early on in this conversation around the sort of the link between primary care and specialist care. I really think that you can tell specialists who’ve never worked in primary practice, have, you know, who haven’t maybe had that experience of what it’s like, you know, if they’ve ever worked in a referral setting where there’s all these tests available. Sometimes money might not be an issue. And I think it helps to have that balance from primary care for sure. So, Stein, something you said there, you take pride now in the minimalistic approach. Let’s just sort of pick up on that. So how do you approach a case with regards to the sort of tests that are available.

I’d love to be able to give you an example of a medicine case or an endocrinology case. I can’t even say the word. But how do you approach a case when you’ve got all these tests available? you do it a stepwise approach? Do you do a panel of tests and see what the results are? You were saying there, feed that back to primary care vets as well. Just tell us a little bit about your approach to cases like that.

Stijn Niessen:

Yeah. Yeah, yeah. Ooh, we can do a whole podcast series on that one. But indeed, I mean I’m a big fan of sticking to the problem list, which is generating generated from the physical exam and the history. And that’s for me the only way forward, you know, because otherwise we’re going to be caught off guard by an abnormality that is just a variation of normal. and we go on a wild goose chase.

So, I say the same thing to undergraduate students as I will say to fellow specialists as well. And I see it all over the place. I interact with specialists across the world via the veterinary information network as well and I notice these differences in approaches of specialists across the pond and over here. And one of the things that I’m trying to really bring across also to my fellow specialists as well, is please stick to your problem list.

You know, you’ve got you’ve got a vomiting dog or cat. And now whether or not I’ve got a s positive spec LI, yes or no, it actually is not going to impact much what I’m going to think about that animal, because I still need to figure out if this could be a secondary elevation of the spec PLI or it’s the primary. I still need to do tests because this dog could still have a form body.

And needs to be operated on with the elevated spec PLI. So, I can then turn back on myself and saying, why did I run the spec PLI in the first place? Then so this is the critical approach that I think is very useful to have about anything. So, I always get a bit itchy when people talk about a minimal database, you know. Like I that that can be so unhelpful and lead to unnecessary testing to follow up on changes that biologically are going to occur regularly in a healthy animal because they’re just an outlier or they’re not relevant to the problem with which this animal is presented with. You need a good pre-test probability for any positive test to have any relevance, and the chances of a false positive are humongously high if you have run a test that was not relevant to the problem list.

So, for me it’s the problem list. And especially and Lucy will probably echo that. In in internal medicine, we see these patients with six, seven different diseases. And they’re old very often as well. So run a bunch of tests, you know, run them through the CT scanner. You’ll find stuff, you know, that that’s not surprising. So but then you’ve got a problem as well and you’ve got a client that is anxious, you know, because you know there was a nodule there on the spleen, you know, but we didn’t expect that. And now, so and we know that if you do an FNA the spleen, you know, it’s going to be bloody, you know. So what do we do? Ultimately, if you think like that, then you need to take this dog for surgery and take the spleen out and send the whole spleen for histopathology for you to prove that it was not relevant. So that’s a dangerous way of thinking.

When you say I’m a fan of a minimalistic approach or leaving things out, actually it’s not because it’s my hobby. It’s the only way forward for me as a specialist because I know the dangers of adding things, adding diagnostics to my range of tests that I’m going to propose.

Mark Morton:

Yeah, that’s an interesting way to look at it for sure. And we have that to a lesser degree in orthopedics with only a smaller range of tests, I suppose. But Lucy, so when is a sort of staged appropriate, sorry, a staged approach appropriate versus sort of, right, we’re going to do everything in one go, particularly when that sort of might impact.

The patient from a delayed point of view or in a sick patient? Is there an argument that sometimes we do have to do a bulk of things in one go or should we always be focusing on one test and the next and then the next?

Lucie Goodwin:

It’s so case dependent on what you would do and owner dependent as well. sort of this is again why it’s so important we have these conversations with our clients. And I’m very aware that I’m speaking with the privilege of an ivory tower of an hour-long consultation. I get an hour to speak to my clients, and I know not everybody does. So, I’m putting that out there. But it’s just trying to understand what is it that they want? What is their degree of worry?

What are their circumstances at home? Is the dog so scared of being at the vet, in which case they’re like, we never wanna come back, we wanna get everything done in one gore. There’s a really solid argument for doing your entire work up in one gore. If it’s one shot with your anxious dog that you’re never gonna get back in the practice again, absolutely fine, we can do that.

And also, I guess the argument there is for referral practice. If they’ve traveled two hours to see you, they may not be very keen on doing that again. So sometimes circumstances drive us to do that investigation, but that’s still contextualized care because you’re still taking into consideration the logistics of the patient and the owner. But to have a more staged approach, sometimes it is more appropriate to do that. And I guess for me, it can be more expensive to do a staged approach. if we’re talking, I will say if it means we have to do multiple anesthesias, that might be something that we take into consideration or time off work for the owner. can be a little more costly, but it also might save money because if you get your diagnosis super early, then we don’t need to carry on doing all of the additional diagnostic tests on top of that. I get to my decision.

A good example, the chronic diarrhea, like the young dog chronic diarrhea, how much investigation are you going to do on that? And I think as time has gone on, I do fewer and fewer diagnostic tests for chronic diarrhea. Well, all my diagnostic tests is a diet trial. Off you go, here’s a bag of food. I’m not doing anything else because on the history and physical examination, there are no red flags.

And if there are no red flags, and usually maybe the vet will have done a little bit of basic blood work, the albumin’s normal, there’s nothing that’s worrying me, the dog is bright and happy, the owner only lives 20 minutes away, the dog is happy coming in and out with the vet, then we can say, let’s just do a diet trial, here’s your bag of food, diarrhea goes away, great, we never need to see you again, we’ve saved you a lot of money or diarrhea carries on, we can try a different diet, we can get the dog back in and do further diagnostics. I think the red flag is what helps me decide about what do I need a staged approach. If there’s something really worrying, perhaps we will push diagnostics a bit more quickly. But if there aren’t the red flags, and we’ve got a bright, happy dog, then I think it’s absolutely fine to sort of go in that direction, not even just fine, more appropriate for us to do some trial treatments sometimes, and when the stakes are very low and there’s a low risk of harm to the patient in delaying that. I also think sometimes there’s some stage, I’m just thinking of a case I saw recently that the owners were super worried about the anesthetic, they needed a little bit of time to go away and think about.

The anesthetic for the 14 and a half year old dog of what they wanted to do. And so actually they opted to do a trial of some medication for a couple of weeks to see if it made any difference. I felt the medication was highly unlikely to make any difference, but it was unlikely to harm. It made no difference. They came back and had the further diagnostics, but by that time they’d really thought about it and really felt it was the right thing for them to proceed and do the investigation. So sometimes it just helps for our clients just have that breathing space as well.

Mark Morton:

Lucy, do you ever find a barrier there, you know, as we’ve touched on a little bit or a community or a requirement for a different communication strategy with owners where they’re expecting you to do all these tests and then you say, you know, I’m just going to give you a bag of food. You know, do you alter the way you approach that with the owner?

Lucie Goodwin:

And I never assume why they’re there, because I’ve learned this over the years as well. This is something that has to do with experience and time. I saw a patient for chemotherapy and the owners were coming into the office, this is when I was a resident, coming to the oncology department. They didn’t even know their dog had cancer. So, when I was talking to them about starting chemotherapy, they were like, whoa, our dog has cancer. And I was like, goodness me, I’m breaking this news to you. So I assumed you knew because that’s why you’re here.

So, I’ve learned the hard way from making assumptions of what a client may or may not want. So I asked them why, know, normally we’ll have the, you’ve been, I’ve got everything you want from your vet. I’d like to hear from you. I’m going to do an examination. We’re going to have a discussion. And I want you to tell me why you’re here and what it is you want out of this. Because actually them setting a bit of a scene to me sometimes help because sometimes they say, we’re not sure, our vet thought it would be good for a second opinion. And it’s like, great, that’s very easy to work around there. But if they’re thinking that they’re going to have CT scans and imaging or whatever, I might sort of say to them, yeah, that is certainly approach we can take. So these are the range of options that we’ve got. So option one, we can do the further investigations, which might be X, Y, and Z. Option two, we do somewhere in the middle.

So, we do some of the basic investigations and trials and treatment or option three is we can wait and see how we go. But it’s that, I just have the conversation with them again, that privilege of the amount of time I have in my long consultations to just basically get there. If it’s hugely deviates from what their primary care vet has said, I will give the vet a call and sort of explain this is, you know, after the conversation, they decided that they’re going to postpone that for now and we might do it further down the line depending on the outcome of this diet trial. to be honest, think as long as we, like Stein talked about it earlier, it’s really important that we are one team, the primary care team and the referral team should be one team. And I think as long as we’ve got good communication with each other, that’s where all our end goal should be to get a happy, healthy pet and a happy owner. So, what are the means it takes to get there? We do it.

Stijn Niessen:

Yeah, maybe we hear an action point here that instead of just sending over the medical information when you refer a patient, we also get a few lines about expectations, you know, the background of it all. and I think that can already make a difference. It’s often very difficult, right? For referring vet to speak to the specialist and vice versa, ’cause you’ve got two busy people that have crazy days so it’s difficult to catch each other on the phone.

But to have some sort of indication of what has been discussed already and what expectations are as well as circumstances for that pet owner combination, that that can help a great deal. So, perhaps there is an action point there in in terms of you know we all accept you need to send some medical information over of your patient so that we know all what this patient has been doing in the past medically speaking but maybe there should be some almost psychosocial background on the patient that is being referred so that we’re more likely to hit the target of that particular referral.

Mark Morton:

Yeah, it comes up again, doesn’t it? The conceptualized care, it’s all about communication with both the owners and with primary care vets in our setting. Stein, maybe with your outcomes, hat on, from a quality of life approach, how do you communicate with owners the potential benefits of an advanced treatment option versus the potential for complications versus the treatment burden on owners. How do you piece all those things together in a consultation?

Stijn Niessen:

Yeah, so ideally we live in a world where owners have already been primed to the concept of analysing quality of life. So that that’s my ideal world and you know I’m aiming for it by the end of my career. That actually a part of going to the vets, the regular vets, will be that they do a quality of life surveys and get taught what quality of life means in a pet. And they do that when that they’ve got a puppy kitten and they do it at the vaccination at one two three four five years of age and are nice electronic means to doing that so ideally we live in that world in the future so that actually pet ownership comes with going to the vets for preventative care and other care regularly but also education about what it means for a dog to be happy a cat to be happy and also the pet owner bond to be of a of a positive nature and therefore once they get ill and might need a referral we already have that background of understanding of the words we use and and what what you know our moments in a day’s life of a happy dog cat that that started to disappear or be altered by the disease process that we are getting this referral from for now we don’t live in that world yet, so very often I therefore, you know, just during my history taking already make them commit to some quality of life assessment. and that starts off in very simple, you know. So give me so yeah I understand, you know, your dog has got uncontrolled diabetes and you talk as if he’s not happy at all.

So if you would describe your dog in terms of a range of zero to ten, zero being miserable, we need to do something, otherwise we need to consider letting him go, versus ten, you know, he’s happy as Larry, you know, it is no problem. Why are we here today? Where are you now? and then usually, especially if it’s a couple presenting the dog to you, the you’ve got a kerfuffle and a discussion, it’s easier when it’s with just one person.

But then they eventually land on a number, and I don’t care too much about that number, but we’ve landed on something, and that can be the starting point. Often I also introduced some more sophisticated, validated, psychometrically validated quality of life tools, but that’s often then after the consultation. I you know I sent them some links. we’ve got this independent website which is qol-pet.com.

Which we’re trying to get as many of those validated quality of life tools gathered, which anyone can use. It’s not sponsored, no advertising. And if you find something that is missing there, then let us know. We’ll add it to it. So so then clinicians can find diabetes. Do we have quality of life tools there? Yep, we do. And they can use those questionnaires which are validated by interviewing hundreds and hundreds of diabetic pet owners about quality of life.

They can go through those surveys with the clients, or the clients can do that themselves. And that that then frames everything differently. because then I’ll go through the options, what we can do and what we need to do. Because if we’re talking about an animal with a two out of ten quality of life, you know, there is urgency there. We’re close to you know having conversations about euthanasia.

Whereas if we’re talking eight, nine, I might have a bit of luxury of time. and that will influence, therefore, how rapid we progress with interventions. and this is, I think, the way we should all be doing it in the first place. And once we have established a plan of action, we’ll circle back to that as well. So, we’ll do once again an assessment. And that can be the crude one, zero to ten, but ideally, we do more sophisticated means so that we can come up with particulate target areas, you know, we might come up with this fantastic diabetes management protocol, but in our quality of life tool, we also pay attention to the effect on the lifestyle of the owner. And if the owner then says, Yeah, you know, he’s fantastically controlled now, but I’m miserable because I’m missing my salsa lessons every Wednesday, Thursday, and Saturday. So, you know, I’m not enjoying having this dog. This dog is becoming a bit of a resentment to me, then it’s good for the veterinary team to know that.

And to make practical decisions. Because at the end of the day, we practice companion animal medicine. And I always say that in my lectures as well. And we get taught a lot about the medicine, especially as specialists, right? It’s all about the medicine. Which enzyme does what? Blah blah blah blah blah. But the medicine should always be inferior to the animal, and it should be on par with the companion bit of companion animal medicine. Because without having that companion on board, we vets can say whatever, do whatever, propose whatever, it ain’t gonna fly, you know? So, we’re not going to be able to get the results we want to using the medical knowledge that we have. so that’s why, you know, when we talk about these concepts, I I make it way more simple and say we practice companion animal medicine and we should pay attention to all three of those facets. And if you want to attach gold standard, silver standard, contextualized care, actually.

We already had the wordings. It is companion animal medicine that we practice. so yeah, I don’t know if that’s an answer to your question. I tend to waffle away on this topic very quickly, but integration, integration of these quality of life tools as early as possible. And if I get a case referred, and that’s more than often the case, and it hasn’t been introduced yet, yeah, I’ll just start introducing it. And clients love it.

Mark Morton:

No, no, it’s… No, no.

Stijn Niessen:

You know, they love it really. Because they see behind the scientists that we all are, they see the human who cares about animals. because you’re asking questions that probably haven’t been asked before, you know. so actually if you if you don’t believe in it, use it as a marketing trick because clients love it. And I hope of course that we all believe in it.

Mark Morton:

Yeah, I mean, I would say from the experience with the Crucial Registry, clients absolutely love being involved in the care, in monitoring the outcomes. It shifts that. If you’re referred a case and the first thing you say when the appointment’s booked is, could you fill out a load questionnaire. So that’s an outcome as we have in orthopedics and explain to an owner why you want them to do that even before the appointment, before you’ve told them, the consultation is going to be this amount of money. It’s going to, I think it just gives that, that over to them that you are looking at their animal before, before anything else. And I, I haven’t had a single owner say they won’t take part. That isn’t the same as every owner then taking part, but they all love it as an idea. They, they sort of, yeah, they want to be involved.

And Stein, you ever, so you do sort of a baseline quality of life measure and you would repeat that at various stages. Do you actively talk about quality of life expectations maybe in relationship to a score, maybe not, but you know, if we’re going to do X, I would expect the quality of life of your dog to be this during the treatment and afterwards it would be this.

Stijn Niessen:

Yeah, so unfortunately we don’t have as much actual evidence on that because most research that has been done in the past has not involved these parameters, which is a shame, but you know, let’s look forward and prospectively start to do that. but indeed I you know, we always want to see those components improve and it also works with some owners are a little bit blind to the suffering of their animal. I I think we’ve all had those type of owners as well, right?

And that actually can help then to show that our intervention actually is failing. And that’s important to also then demonstrate and objectively be able to show or actually, you know, we you say it’s going better, but when I ask you about specific situations in the daily life of your pet, you’re actually not reporting improvement in that.

And unfortunately that that means that we’re not achieving what we were hoping for, because we wanted to see improvement in mobility or interaction with you as a pet owner, or return to the routine. Routine is very important for many pet owners and pets themselves as well, and we’re not getting this because of the disease process that we’ve got there. yes, we we we we are held to account basically both ways.

I guess, you know, a an example is the Cushings dog. many vets are scared of Cushings because of us endocrinologists not having taught them well enough how to diagnose it. And then you know you’ve got trilostin, and maybe that causes difficulties, you know, might get Addison’s. So there’s a sphere of being anxious about Cushings in general. I think that’s fair to say. I’m looking at Lucy at the same time, she’s nodding, but we’ve measured quality of life in cushionoid dogs before and after treatment. And when you do that in a detailed fashion and you you you unleash psychometrics on it, which is a field of statistics that has been there for donkey years and also been applied in paediatrics, so in human medicine where the patient also cannot speak, and therefore it is the by proxy, so the parents, caretakers of these babies and toddlers.

That have to report on the quality of life of the babies and the toddlers. Well, we have that same situation, right? With our pets, the caretakers need to tell us something that will influence whatever comes out of the quality of life measurement. That has been around forever. And if you measure that in those cushion dogs before and after starting medical treatment, you see a distinct difference. And you see that lasting as well. The Kushinoid dog without treatment, they might still be eating well, you know, and owners love that. But yeah.

They’re pathologically eating, of course, but they’re wasting away and they’re becoming old very quickly. And that’s the steroid effect. So when we’re not treating, you know, you can document literally the aging process. and the longevity will be shorter because people will say, Yeah, yeah, he’s now he’s now eleven, he he’s quite old, right? So and you know, and he had that ear condition as well. So maybe it’s time to be kind and say goodbye.

Our quality of life measurements show that if they had instituted treatment earlier on, the 11 or year old would look like a nine-year-old, and therefore the 11-year-old could have become a 14 or 15-year-old. But these are silent killers, especially in internal medicine, right? The chronic conditions that they often don’t kill the animal as such, but because they come together with the aging and then the perception of the owner that at some stage, you know.

They are too old to justify them going on. It leads to that euthanasia conversation. and therefore actually, you know, it the real story is that if two years earlier we had done the right thing and we had listened to the evidence and acted according to it, we wouldn’t have been in that situation where we were talking about this old dog that, you know, it’s fair now to say goodbye. But that’s what you learn from quality of life research when you actually measure it and document it and that you can apply to the individual patient again.

Mark Morton:

Great. That’s really interesting. Lucy, so just to sort of finish up on the sort of the treatment sort of section of this conversation. So, you know, as you’ve touched on, we’re in a fortunate position because we have lots of time, a of a broad brushstroke, but we have owners generally that on the scale have more resources. They’re quite often insured. You know, they were aware of potential costs beforehand. And I’m not passing any judgment there, but just as a sort of, so, you know, how much should we guide options owners on treatment options? How do we answer that question that we’ll all be familiar with? What would you do if it was your dog or cat?

Lucie Goodwin:

I am slightly controversially. I don’t know. I don’t shy away from answering that question because I think especially in the field that we’re in and you Mark, some of the advanced surgeries you’re doing, a client is going to want to know, would you do a hip replacement in your own dog? Surely. Of course they, they’re going to want to know that before they do it to their own dog. think when we have really complex cases.

And I’m thinking of one recently. So it’s an endocrinology case of really complicated adrenal disease that wasn’t cushions. And they’re asking questions that they, without a degree in physiology, they can’t understand. sometimes even like vets struggle to understand some of these concepts because they’re so…The case is so challenging and so rare, unless you’ve really read up on it and have a special interest in it, you’re not going to know the ins and outs of this case. So how on earth could we say an owner can give any sort of informed consent when we’re talking about certain treatments because of the level of knowledge that they would need to give truly informed consent is beyond what they can do without going and doing a degree in that subject area.

But of course, we can’t make decisions for our clients either. So, I think it’s really important that we don’t coach, coach is probably the wrong word. We don’t tell them what to do. We present what the potential options are, the pitfalls, the benefits of the different things that we have available. But ultimately, I think it is important to take it into consideration. What would you do if it was your own dog?

I don’t necessarily say, give them a straight answer because it’s unlikely I would ever be in the same position because as a vet, might have noticed things earlier or I might have different resources available to me. might, you know, I have different things available that would allow me to do more than them. But I can think like, what would I do if it was my mother’s dog? What would I be advising my friend who rung me and said, this is going on with Benji. What would you, what do you think I should do? And it’s that case of just saying,

Or asking the client, is the most important thing to you? What is it that you really want to get out? And let’s try and work together and find out what the outcome is. If it’s about a major surgery and whether or not they go down a major surgery, I will say, I’m not sure what I would do if I was in your position, but I know whichever decision we make, we will find a way to make sure your dog is comfortable and happy.

And maintaining that quality of life. So I don’t, I won’t shy away. I will sometimes answer and do say what I would do. I’ll caveat it with, I’m not you. And I have a different set of circumstances to you, but I will try and help as much as I can in them getting to that decision so that they’re happy. And I think one of the things I will always say, I always, but when it’s a big decision and it’s weighing really heavily on somebody’s mind, I sort of say, how would you feel if you go down this route and we have a bad outcome? It’s a high risk surgery and your dog dies. I want you to say you did the best you could for your dog and not be kicking yourself saying, I wish I’d never had the surgery. And I want you to be going into that, into this procedure with that mindset.

So that you don’t blame or judge or put guilt upon yourself if the outcome isn’t what you want it to be or what any of us want it to be. It’s just trying to make sure that they’re comfortable with that decision making process, so they don’t carry the burden. I think like I mentioned to you before, Mark, think as I’ve aged, burden is something that’s become perhaps the thing I focus on more in the contextualized care.

I think, especially again in meds like Stein said, we might have patients with six different diseases, the management of which can be incredibly intense. And if you’ve got, again, thinking of a patient I’ve treated recently, lovely dog, lovely owner, really complicated medical problem, like really challenging, and really difficult to get hold of the drugs that the dog needed. Thankfully her daughter was a hospital doctor so we could get prescriptions filled in the hospital to get the drugs.

But ultimately, even though the drugs weren’t causing side effects for the dog, the dog stopped wanting to interact with the owner because it was sick of being medicated, would run away, would hide in the corner, and the bond just totally fell apart. And it’s like, we’re achieving nothing here if ultimately, exactly like Stein said, it’s a companion animal. And pets are also meant to enhance our quality of life. That’s why we have them, so that we have a good quality of life.

Nobody’s enjoying that scenario. The owner’s breaking their heart that their dog doesn’t want to be with them anymore. The dog is hiding from the owner. We’re not getting a good outcome. And so it all comes back to that, maintaining welfare, maintaining that bond and making sure that you’re supporting a client through what, you know, it’s very rare any decision is totally right or wrong. We were operating shades of gray and we just need to sort of…make sure the animal is not suffering. We’re there to advocate for them, but we have a responsibility to the client. Me asking a client to give 10 drugs a day on top of their full-time job, on top of looking after young children, that’s not very fair on them, of me to do that to them either. So it is that balancing of everything together. I’m not sure I answered your question then either, Mark, or if I’ve just waffled.

Mark Morton:

Yes. No, no, no, I think they did. And I would wholeheartedly agree with that. I have a very similar approach and, know, to use your example, a dog that knee that has been referred for hip replacement. Well, we here see lots of dogs that are referred for hip replacements that don’t go on to have hip replacements. Because when you assess them and you talk to the owners about how they’re doing clinically, you know, we use an outcome measure to measure the impact on them.

We talked to the owner about the potential for complications. I use a very similar line. If you had a complication following a hip replacement, as an owner, you never want to be in a position where you say, I wish I hadn’t bothered the dog. My dog was absolutely fine beforehand. Whereas if you’ve got a dog that’s really struggling, their quality of life is really impacted, a complication or something that doesn’t go quite to plan, it’s easier to deal with because you know that that was the right thing for the dog to do because its quality of life was not what it should be. And that for sure covers a big gray area in well, orthopedics and medicine. It’s no different. So, we sort of touched on this a bit earlier. I’ll ask you this, Stein. where the sort of three of us experienced in very small fields now, know, we asked me when my dog needs a vaccination, I’d have to look it up. But, but in our sort of our little sphere, orthopedics, medicine experience that we’ve gained over years really, really helps with clinical judgment. And that can, I think, improve care from a, from the point of view of doing more focused investigations, as we’ve talked about.

And we’ve talked about the conflict that can sometimes be with owners when they’re expecting you to do more. To come back to something we talked about earlier, how do we teach that to residents and colleagues and give them enough support to manage that uncertainty? And I suppose if you maybe take it back to primary care, one of the things that came up in the forums we had around contextualized care was the need for defensive medicine.

So either at a sort specialist level or a primary care level, how can we help junior colleagues and colleagues in primary care sort of with our experience manage that uncertainty? Do you have any pearls of wisdom?

Lucie Goodwin:

Mm.

Stijn Niessen:

Yeah, no, that’s a very, very good question. I think people like us can role model and that’s quite powerful, I think. And I mentioned before that example in rounds in a multidisciplinary hospital, maybe in academia where everyone is trying to pick holes into a story, to get the best possible outcome and make sure that we’re completely, you know, solid on our plan according to the latest evidence has a side effect. But you can also be in those rounds and say, well actually I don’t know that. I need to look that up. And yeah as a senior person say I haven’t got a clue what what’s going on with that patient yet. but we can make a plan of trying to figure it out. you know so I think the way we communicate is very important especially as you know a slightly more senior specialist and it comes from a background right like our schooling system in in the western world but I think everywhere is based on a student not showing what they don’t know. Because you go into an exam, it’s proving what you know. Prove what you know and let them not show what you don’t know because you’ll be punished. So that happens in elementary school, high school, it certainly happens in vet school as well.

And so there’s a task there at vet school level already. The whole exam system is based on hiding what you don’t know. And that then comes into the first job that you’ve got as well. You’re trying to show to your first boss I know lots of stuff, you know. So and that’s even exaggerated in specialist training as well in the in the settings that we’ve been trained in as well.

So, there’s a almost a punishment to not knowing. We should flip that around and actually focus on the learning. And this is also educational theory, right? You learn for the longer term by positive learning. You learn very quickly for the short term through negative learning. And we know this from dog training, right? So if you want your dog to quickly stop stealing your food from the kitchen top.

You should punish it, you know, because quickly he will stop doing that. But when you’re not around, he will definitely go and grab that food for that piece of pizza from the kitchen top, right? So that’s not good learning at all. It wasn’t learning in in an essence. Whereas if you reward that dog by you know offering an another more appropriate treat whenever he doesn’t steal food from the kitchen top.

That’s long-term learning and now taking it back to us vets and vet specialists as well so rewarding the fact that somebody is honest about some not knowing something is a very valuable thing. and nowadays with AI and stuff you can look up anything so in a way what we need to really teach underneath is that you can find the information somehow, somewhere at some stage.

But it’s the attitude to the whole process that is the most most important and therefore logic should be rewarded even though you don’t know the facts yet finding a pathway and realizing that there are multiple pathways and and even daring so having the courage to to to communicate that even to the client and and this is really powerful and actually a trick that I think learned

I learned way too late and I wish I used it more often. And I call it a trick. It isn’t a trick, it is it is what it is, basically. Very often I tell a client openly, I haven’t got a clue what’s going on with your dog. and this is why you came to me, because all those very intelligent vets, they didn’t know what was going on. and that’s why they send it to me. so I’m not going to guarantee you that I’m going to find out what’s going on.

But I am going to guarantee you that I’m going to be logical and thorough in trying to find this out. And hopefully we can design a plan that that you know suits your particular circumstances, that is adapted to how your dog slash cat is in terms of character and in terms of what their needs are.

And then we’ll see whether or not we bit by bit can gain understanding of what’s going on there. but it’s important to know that that in medicine there are huge areas of uncertainty and especially in veterinary medicine, and especially also because we often can’t do all the things that can be done in human medicine to obtain that level of certainty that we hope to get. We need to together accept a level, a significant level, of lack of certainty. And I think these conversations that we’re having right here, right now, should be happening more on a monthly basis in those residency trainings where those specialists are being created. because that that would help a lot. I didn’t have many of those conversations. There were a few senior clinicians that maybe were better at voicing that as well.

And one of them jumps to mind, Jane Eastwood, I had the pleasure of working with and she always told me, as long as you’ve got a plan, you know, as long as you’ve got a plan then you know you can work from there. And that was a real consolation. So I thank her still for for that one liner. But these one liners in an education of a specialist can be very important, you know, ’cause some of some of them really stick for a lifetime as a testament to that quote that I just gave you just now.

Lucie Goodwin:

I think remembering the veterinary medicine is a team sport, it’s really important. It’s not about being the individual, you work as part of a team because none of us can do our job without the benefit of every, especially in referral practices, we were so heavily reliant on the other vets and the other disciplines to be able to do our job, that’s important.

I’ve got used to sort of saying to clients, you know, I work as part of a team and the benefit of working as part of a team is I’ve got a whole other bunch of heads that can input on this case. So I don’t know right now what’s going on, but I’m going to discuss him with my colleagues and see what, see if they’ve got any thoughts to add in. And I think I have no shame in saying to a client like Stein that I don’t really know what’s going on, but we will get there.

Stijn Niessen:

Yeah. And then these type of conversations where we have this not-for-profit mentorship scheme, the virtual veterinary internship. So, every year we take on hundred and fifty new grads, a mixture, some are not new grads. And these conversations we are having now, these are the conversations that I wish I had earlier on in my career. ‘Cause I was also aspiring to be the know it all, be it all kind of person that would have an answer to everything and that can make you miserable, you know, because you’re trying to achieve something that is not achievable and not fun either. It’s not fun.

And as soon as you’ve got these a bunch of new grads actually say that out loud and they’re saying to each other, I was this week in the consult room and I actually didn’t think I was worth the consult fee because you know I didn’t know what was going on there and I wish the dog or cat was seen by somebody else because they would have done a better job.

You know, as soon as somebody says that, then you you’ve got you know tens of others saying, Well, I actually I think like that as well. And that’s wrong, right? Because they’re thinking something really natural that possibly I’m looking at you both. We have all felt. and let’s speak about it. It’s very normal in veterinary medicine. Most of the times you don’t know. and it’s about building the structures to getting to know attention a tiny bit more and then use that knowledge to your advantage.

But acknowledging the big black hole that we often don’t know is very important not to become miserable or to expect things that you can’t really expect from the profession or from yourself and that and that’s the important bit. So, we can talk about imposter syndrome, imposterism and that sort of stuff. But vocalizing this early at vet school and in our first jobs but also in the specialist training.

I think is essential and we should really, really do more of.

Mark Morton:

Yeah, I would agree with both of you there. I’m much happier as I’ve become more experienced to say, I don’t know, but I’m going to try and find out and this is the way we’ll do it. yeah, I think that is an experience thing and we need to help our younger colleagues. Lucy, you brought us nicely onto my sort of final question, of talking about the big teams that we work in.

And I think this is appropriate, whether it’s a big team or a smaller team, but in big referral hospitals, this can be a particular thing to consider, think. One of the barriers in when it came out in the roadmap about contextualized care, but in one of the groups I was involved with at one of the forums we had about contextualized care, one of the themes was talking about continuity of care.

Lucie Goodwin:

Mm.

Mark Morton:

And that came out as a big barrier to practicing contextualized care. Now I’d always maybe naively just thought that meant seeing the same person every time. When we discussed that at the forum, it came out that it actually, you know, doesn’t necessarily see the same person every time, but the person you’re seeing needs to know what the plan is and what your expectations are. How in a big referral hospital?

Do we keep the whole team involved when we’re sharing cases? How do we make sure the continuity of care is there that allows us to practice in a contextualised way?

Lucie Goodwin:

I think it’s the same for everyone. It’s a very boring answer, but it’s like I would say, very good note keeping and being very clear in like documenting your thought process in the clinical records, having a plan for what you’re going to do for when the patient comes back in, having conversations within the team. again, I generally have some awareness of what my colleagues have going on in the hospital.

It doesn’t mean you need to have the detailed knowledge of each individual case, but you have an understanding of how everyone works. You’d support each other, have a very, not necessarily similar approach, but have an understanding of each other’s approach to a case. And so it’s sort of easy to pick up if somebody’s not in the practice for any reason. And I think, again, communicating that to the client and just making it very…I will not be in next week.

So, the next time you’re coming in, you’re going to be seeing this person, keep a diary. This is what they’re going to want to know. Share that information when you come in and I will make sure that they will know that they are expecting to see you. My notes will be up to date. There will be a plan in there. And I think that’s essentially what I do within team. And then obviously there’s sometimes track, track, interdisciplinary referrals. So, I might be referring something on case on to the soft tissue team, for example, again, is having those a formalized handover. So however that looks sort of with us, it’s a written handle with a medicine to surgery transfer. I normally follow that up with a conversation because exactly like Stein said earlier, the psychometric side of things. Is it that the right words Stein? Yes. Of going but actually, so this is what it says on paper, these are my thought processes. So you understand what we’re trying to achieve. I can give a bit of back

Stijn Niessen:

Yeah, yeah, yeah.

Lucie Goodwin:

to what maybe the owner’s anxieties may be about the case. So if they come in to see the surgeon, I can say, know they’re gonna be really anxious about the anesthesia in this patient. So can you take a bit of time to talk about that? I don’t necessarily write that on the form, but it is, it’s just all communication, isn’t it? And ensuring the best we can to make sure within the team that the client does get that continuity. I guess for us, the bigger issues maybe with continuity. It’s more not within our hospital but with our referring vets and that’s where it’s so important that we are absolutely keeping them in the loop with anything that we’ve said or done so that the primary care vets that they see it understand and also I think I don’t know if it happens in other disciplines but I think medicine or certainly when you start to have end-of-life conversations a lot of our clients want to speak to their own vet before they make big decisions because

They’ve met me for like half an hour. They don’t know me from Adam. I’m just sort of this stranger giving them this information. And if they make in these big calls, they want to speak to somebody that they’ve been a client of theirs for 40 years with 10 different pets. They want their opinion. So, I think it is really important that we maintain that continuity with the primary care vet. Who is the primary care vet? Is their main caregiver really for their animals. So, I think it’s that communicating, sharing intention to just ensure that the client can trust when they come in that whoever they see in, whether it’s back in the referral hospital, back with their own vet, that they trust that the appropriate information has been shared.

Mark Morton:

Great. Well, I think that wraps up this conversation really nicely. Thank you so much for joining the RCVS Knowledge Contextualised Care podcast. I’ve certainly really enjoyed the conversation. I’ll be bringing my five month old Labrador around to your house Stein to train him to stop eating pizza off the countertop for sure. I think we’ve covered a lot there and

I mean, my thoughts reflecting back would be it all comes back to communication. We’ve said that word many times during this podcast. So thank you to everybody who’s joined and listened. We hope you found some value in this. And yeah, thanks again.

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