The Role of Veterinary Specialists and Referral Equine Hospitals

Words by Dr Brett Tennent-Brown BVSc, MS, Dip ACVIM, Dip ACVECC, U-Vet Werribee Equine Centre. 
As seen in Horses and People Magazine May 2017.


Image: Professor Chris Whitton, equine surgeon at U-Vet Werribee Equine Centre (centre). In addition to more powerful x-ray units, the ultrasound machines at referral hospitals typically allow greater resolution and detail when evaluating the tendons and ligaments of the equine limb than is possible in ambulatory practice.

Like specialists in human medicine, veterinary specialists have extensive experience and expertise in a relatively narrow aspect of veterinary medicine. As such, specialists in equine surgery or medicine are often able to provide services that might be beyond what is possible in general ambulatory practice.

Although not all specialists work from referral hospitals, many do and these facilities enable them to provide an exceptional level of care to your horse.

Understanding what a hospital-based specialist can offer you and your horse is important when trying to decide whether your horse should be referred for specialist evaluation.

What is a veterinary specialist?

Veterinary specialists tend to remain more broadly focused than their human medicine counterparts but, as a whole, veterinary practitioners are becoming increasingly specialised.

Part of this drive toward specialisation is the ever-increasing body of veterinary knowledge. Remember that, unlike human doctors, veterinarians must deal with a wide range of animal species that often differ considerably in their normal physiology and which might be affected by vastly different disease processes.

As a consequence, it has become increasingly difficult to have a comprehensive understanding of the diseases that could affect all of the species that a veterinarian might be expected to deal with!

Although there is still a role for the James Herriot-style mixed animal practitioner, most graduating veterinarians plan to practice on either small animals (cats and dogs) or large animals (horses, cows and other farm animals).

Many specialists might just work with a single species and this is particularly true of large animal specialist practitioners, many of whom just work with horses.

Veterinary specialists narrow their focus further than just small or large animals; the most common specialities in large and small animal practice are Surgery, Internal Medicine, and Emergency and Critical Care - and this is not the end of it! For example, some specialist surgeons will concentrate on orthopaedics, while others work primarily on soft tissue injuries or diseases. Equine orthopaedic surgeons primarily treat injuries to the bony elements of the limbs, whereas soft tissue surgeons often have a particular interest in abdominal surgery, such as treating horses with colic that require surgical intervention.

Rather than just focusing on one or two animal species, some veterinary specialities focus on diseases that affect just one part of the animal, such as the specialties of cardiology or ophthalmology, or on a single disease process, like oncologists who treat veterinary cancers.

Veterinary cardiologists, ophthalmologists and oncologists are usually able to diagnose and treat conditions across a wide range of veterinary species, although many spend more time working with small animal patients.

Finally, there are several groups of specialists that animal owners might never meet, including veterinary anaesthetists, radiologists and pathologists. These specialist veterinarians can all provide invaluable insight into animal diseases.

As a point of clarification, in Australia, veterinary specialists are veterinarians with speciality level training who have registered as a specialist with the appropriate veterinary regulatory board. There may be veterinarians with extensive specialist level training, skills and training that are not registered with the regulatory board.

While those veterinarians are not allowed to call themselves specialists in Australia, they are perfectly capable of providing a very high level of care to your horse. This is obviously slightly confusing, so it is important to understand the sort of training that qualifies a veterinarian as a specialist in Australia specifically.

How do specialists become specialists?

Veterinary school graduates receive extensive training and are well equipped to tackle most of the challenges they will encounter in general practice. However, some veterinarians decide they would like to know more about a particular area of veterinary medicine, so they are able to provide more tailored services for their patients.

The first step in becoming a veterinary specialist is usually to undertake an internship (i.e. become an intern) in either small animal or large animal practice. Internships are usually one year long and most are rotating - that is, the intern spends time with surgery specialists, medicine specialists, anaesthetists, and so on. The aim of these internship programs is to expose recent veterinary graduates to high level veterinary practice under the supervision of specialists in a range of fields.

Following successful completion of an internship, veterinarians who want to gain specialist qualifications will apply for a residency training program. Veterinarians undertaking residency training programs are called residents most work very long hours and so reside or are resident at their hospital!

Residency training programs are usually three years in length and have a narrower focus - for example, large animal medicine or large animal surgery - than internships. As a part of their training program, residents are required to study the scientific literature around their chosen speciality and many will complete a research project investigating a particular aspect of veterinary medicine.

There are a number of governing bodies that oversee and regulate veterinary resident training programs. The most well-known are the American College of Veterinary Internal Medicine (ACVIM) and the American College of Veterinary Surgeons (ACVS), and their European counterparts - the European College of Equine Internal Medicine (ECEIM) and the European College of Veterinary Surgeons (ECVS).

Each college has a set of very rigorous requirements that residents must meet, and a certifying examination or examinations that must be passed. Residents that fulfil the college’s requirements become Diplomats in that specialty.

The Australian and New Zealand College of Veterinary Surgeons (ANZCVS) oversees many of the residency programs in the Southern Hemisphere and this college has particularly stringent standards. Veterinarians who complete ANZCVS sanctioned residencies become Fellows of the ANZCVS.

Regardless of the governing body, veterinarians who have gone through a residency program and have fulfilled their college requirements (i.e. Diplomats or Fellows) have extensive knowledge and clinical experience in their chosen area of expertise.

“Many equine internists have extensive imaging skills and are particularly adept at ultrasonography. This is a vital tool.”

Understanding what a surgery specialist does is fairly straightforward, although many of the procedures performed by veterinary specialist surgeons are very complex and require an incredible level of skill. It is a bit harder to understand what it is that a medicine specialist, or internist as they are often called, does.

In the equine field, a large portion of many medicine specialists’ jobs involve treating very sick horses on an emergency basis. Many internists have a deep interest in neonatal medicine and will have extensive experience treating critically-ill foals.

Other emergent cases commonly managed by internists include horses with diarrhoea and pleuropneumonia. In many hospitals, it is the internist who will first evaluate horses with colic and help make the decision about whether that horse requires surgical evaluation of the abdomen. It is also often the job of the internist to manage those horses with colic that don’t immediately require surgery. Although internists usually don’t perform surgery themselves, they are often responsible for the post-operative management of these horses.


Image: The high-speed treadmill at the U-Vet Werribee Equine Centre can be used to simulate high intensity exercise and allows assessment of respiratory and cardiac function.

Liver, kidney and heart disease are, fortunately, fairly uncommon in horses. However, when diseases of those organs do occur, an internist is well equipped with the knowledge and skills to make an accurate diagnosis and devise an appropriate treatment plan.

Many equine internists have extensive imaging skills and are particularly adept at ultrasonography. This is a vital tool when evaluating horses with problems, such as weight loss, persistent colic or diarrhoea, and infections of the respiratory tract. Evaluation of blood work is often is an important aspect of managing medical cases, and equine internists have a deep understanding of the subtleties and intricacies of laboratory results. Internists can also recommend and interpret testing that might not be routinely offered by general practitioners.

When should my horse be referred for specialist evaluation?

This is a difficult question to answer because there are so many factors to consider when deciding whether a horse should be referred for specialist evaluation. In most cases, horses are referred to a specialist by the attending veterinarian, but it is also reasonable for owners to suggest or seek referral.

There are a number of things that are easier to do at a hospital or can only be done at a hospital. These include complex surgeries (particularly those requiring a prolonged general anaesthetic), continuous administration of intravenous fluids and other medications, and continuous and complex monitoring of patients. Many referral hospitals have laboratory equipment on-site or nearby, allowing frequent and rapid laboratory evaluation (blood work) that is absolutely critical in managing very sick horses.

Most hospitals will have veterinarians who have expertise in a range of areas who can be consulted in the management of your horse. In our hospital, for example, both medicine and surgery specialists frequently evaluate the same horse.

Our hospital also has a group of highly trained nurses who work around the clock, and veterinarians who are continuously available to monitor and treat hospitalised horses, and this is a feature of many referral hospitals.

In addition to knowledge, skills and equipment, one of the most important commodities that specialists working in a hospital have is time. In our hospital, we will invariably spend hours systematically evaluating a case. This is simply often not possible in ambulatory general practice.

It is not always possible to get your horse to a referral hospital, but that doesn’t necessarily mean it can’t benefit from the expertise of a specialist. There are often specialist veterinarians who are able to travel to examine your horse with your regular veterinarian. Furthermore, most specialists are more than happy to discuss difficult cases with the attending veterinarian or horse owner. 
Is referral medicine expensive?

The short answer to this question is, unfortunately, yes - referral medicine and surgery can be very expensive. There are a number of important reasons why this is so, but it is important to recognise that referral hospitals can also provide tremendous value for money.

At our hospital, we have state-of-the art equipment that is tremendously expensive to purchase and maintain. We also have a large facility that allows us to provide exceptional care for your horse and this too is very expensive to maintain. However, our greatest expense is the cost of providing, 24-hour, 7-days a week high-quality nursing and veterinary staff. This level of staffing is essential for the critically-ill cases that we see at our hospital, but can also be important in more routine cases.

Having said this, we recognise that referral might not be an option for some horse owners and most specialists are happy to discuss options to fit within a particular budget.

Conclusions

Specialist veterinarians have undergone years of rigorous training to develop expertise in their particular area of interest. They are often able to provide guidance in the diagnosis and management of cases that is beyond the capabilities of general practitioners.

Many veterinary specialists are based at referral hospitals that are able to offer horse owners a wide range of high quality services. Referral medicine can be expensive and this is important to consider when thinking about taking your animal to a specialist.

However, most specialists are more than happy to work with owners and their veterinarians to provide the best possible care for your horse.

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