Maintaining Clinical Standards in Practice

“Sometimes wrong but never in doubt” is an aphorism that could be ascribed to many senior equine practitioners in the 1960s and 70s.  George Bernard Shaw’s comment that information imparted confidently by a “grey beard” readily becomes received wisdom rang true. Clinical standards in the sixties and seventies were not only basic but more importantly they were not questioned.  It was perceived that in private practice we were too busy and it was too expensive either to achieve a high standard of clinical protocols or to evaluate the outcomes of our cases. This is manifestly not the case.

We all know what clinical standards involve: they are in the RCVS Guide to Professional Conduct. But at the coal face of clinical practice, with all its pressures, they are not always easy to achieve.  This article is not intended to describe the details of “best practice” for specific procedures, such as the correct way to deploy an intravenous catheter, but to discuss ways in which the daily routine can be the vehicle for maintaining standards.

Use of personal protocols for all clinical tasks. These are based on what is understood to be “best practice” but they should be adjusted in response to complications. Certain questions are good incentives for developing an acceptable routine. Should there be a complication, is there anything we would regret having done or that we failed to do during the procedure? If we had to defend our actions in a court of law could we proudly and confidently stand behind what we did? How publicly humiliating to be asked why we failed to perform an arthrocentesis aseptically on a joint that subsequently became septic. Mistakes are less likely to be made if we stick as much as we can to a routine for everything we do, from examination of the horse to any veterinary procedure we might have to perform. 

Imaging protocols are driven by the quality of the images. Recorded images are a permanent record that reflects how we performed the imaging procedure and they have the potential to haunt us for years.  Do we always properly prepare the horse for ultrasonography and do we take trouble to maximise image quality? Have we taken enough care with positioning for each radiographic projection? Inattention to detail in all imaging procedures can be the cause of a missed critical lesion. A proper routine that covers all the vital nuances should at least avoid regrets.  It may take longer but we have fulfilled our responsibility to the horse and its owner.

Monitoring clinical outcomes.  We know from the literature what “best practice” should be for many treatments and procedures we use, but have we checked that our results reach the accepted standard?  And how many of us can advise an owner that for a procedure we are recommending, a known percentage of our cases have returned to work?  Analysing the data does take time, but an organised follow up system that uses our secretariat will at least collect the outcome data.   The clients have to be proactively contacted; it’s no good waiting for them to call us and most owners really appreciate the interest.  Hard data will often overturn our expectations and guessing is no substitute.  Compared with the medical profession our poor knowledge of outcomes is one of our profession’s major weaknesses.  Evaluating outcomes depends on a real desire to do it, a robust system and good staff.  Even then the disheartening entry on the case notes “lost to follow up”, as well as the extra time required to process the data can be demoralising.  It is our responsibility to try and good or bad it should improve our clinical service to the horse.

Record keeping and paper work. There are no short cuts. Clinical standards can’t be maintained with inadequate records. Whether we are the “write up your notes straight away” type or the “leave them until later” type, the record must contain enough relevant information. This is stating the obvious but poor clinical notes are a major limitation to the evaluation of outcomes and again they have a humiliating side effect if we have to produce them in court.   

This rather sanctimonious article is born of a career in first opinion practice, hospital practice and university clinical practice. In the Liphook practice our main ethic was to perform the clinical work to the highest standard we could, despite the cost, and the standard we have reached was achieved with systems and discipline. But despite evaluating outcomes in a number of large case studies my main regret is that we didn’t do more of this, especially in the early days. That is my regret. What will yours be?

John Walmsley MA VetMB CertEO DipECVS HonFRCVS

Like It Or Loathe It

By Andrew Harrison

Like it or loathe it, “physiotherapists” are part of the armory that horse-owners use routinely for the treatment or maintenance of their animals, whether it is an elite athlete or a much-loved hack and in my opinion they will continue to be so.

In this statement, I use the term “physiotherapists” generically – how often do you hear an owner say, “I got the physio to have a look first”.  The term physiotherapist and chiropractor are protected titles; however, if they are pre-fixed with the terms veterinary or animal, they are not.  The term physiotherapy and chiropractic are also not protected and are used in the Veterinary Surgery (Exemptions) Order 1962: 4(a) any treatment by physiotherapy given to an animal by a person acting under the direction of a person, registered in the Register of Veterinary Surgeons or in the Supplementary Veterinary Register, who has examined the animal and has prescribed the treatment of the animal by physiotherapy. 

Now, does that mean treatment administered by a Physiotherapist, a Veterinary Physiotherapist, an Animal Physiotherapist, a Chiropractor, a Veterinary Chiropractor, an Osteopath, a McTimoney Chiropractor, a McTimoney Animal Associate, a Sports Massage Therapist, a Bowen Laser Therapist, etc., etc.  And therein lies the rub:

-                      How well qualified is the person who you referred the animal to - if in fact you did refer the patient?

-                      When did you last enquire about the qualifications and competence of the therapist that you referred the horse to or more commonly, the person to whom the owner wanted the horse to be referred to?

-                      When you signed the veterinary fees claim form for insurance recommending complementary therapy, did the therapist fulfill the criteria set out by the insurers?

-                      What are the insurer’s criteria?

-                      Are members of the McTimoney Animal Association, who perform chiropractic able to call themselves Chiropractors?

-                      Etc., etc…

According to the Veterinary Defence Society, even though you may have (unwittingly) referred the case to the “physio”, who may or may not have their own professional indemnity insurance, you are still deemed to retain “care & control”.

Arguably there are some musculoskeletal paraprofessionals, whose gait assessment, palpation and diagnostic skills are infinitely superior to our own - although of course they’re not allowed to diagnose.  I am not ashamed to admit it that I have learnt a lot about gait analysis and abnormality whilst working with some of these individuals.  However, we often only call on them as a last resort; when we cannot make a diagnosis and “hospital-pass” it to the “physio” saying, “I’m not sure what’s wrong with him, you’d better have a look!”  Isn’t that somewhat patronising and dismissive of these paraprofessionals?  On the other hand, I think it would also be fair to say that they often treat us with a similar amount of indifference and won’t always ensure that there has been adequate communication both before and after any consultation.  Regardless of who’s to blame, this is a 2-way street and I think that we need to ensure that we, as a profession, are not found wanting. 

Currently the mysterious and murky world of “musculoskeletal paraprofessionals”, which is shrouded in acronyms, lacks boundaries and clarity.  In my opinion, this has resulted in the majority of veterinary surgeons viewing the majority of them with a mixture of suspicion and contempt.  However, these various groups are in the process of attempting to establish a regulatory framework, which will define education and training requirements so that we can be assured of the level of competency of the individual that we are referring our patients to.

Having recently been enlightened about the somewhat onerous education and training, which physiotherapists, chiropractors, osteopaths and some others have to undertake, there is no doubt in my mind that many of these individuals are well worthy of a place at the veterinary table.  Furthermore, in my opinion, it is our responsibility to engage with them if we want to do the best for our patients; and by that I do mean active responsible engagement, which is in the past may have been lacking.

“Physiotherapy” is integral to the success of any elite sportsman or woman, not to mention the important role they play to keep us all “on the road” with our numerous aches and pains; we need to embrace it for equestrian sport and leisure.

   

Mark Bowen - A new era of veterinary politics?

For years, the profession has complained that the RCVS does not listen to its members, that council members were not representative and yet voting numbers in the RCVS elections have been low for years, although now improving. BVA and its specialist divisions, including BEVA, have been the route of communication, holding them to account. The First Rate Regulator initiative calls for it, amongst other things, to enhance engagement and communication with the profession and for it to be seen as a modern and relevant regulator. 

Recently the RCVS announced its plans for the middle tier; advanced practitioners. This is a welcome innovation, recognising a range of post graduate qualifications including certificate exams. There are factors that many are still unhappy about; the £110 price tag for the title and the requirement for old style certificate holders to complete A module CPD. This is particularly galling to some since there is still a perception that old style certificates were more rigorous. I don't believe this is fair, and the inclusion of some of these 'soft skills' does not decrease the rigorous clinical components in the C modules. Candidates work just as hard, if not harder for these qualifications and we should avoid devaluing their efforts. 

A second aspect of the proposal is to remove most post-nominals from the register. This has caused considerable consternation in the profession. This proposal would mean that only a registrable degree would be listed. All certificates, masters (including the MA awarded at Cambridge), doctorates and diplomas would be replaced by the listing as advanced or specialist practitioner. The idea is to simplify public understanding and mirrors what is done by the General Medical Council. An online petition generated over  1200 signatures, while only around 300 had responded to the initial consultation in 2011. Why did so few respond to the working party, and so many respond to a petition? Have we become more engaged with veterinary politics, or were the proposals inaccessible to the members? The obvious response is that they were clearly accessible to all, details were in the RCVS news and widely publicised online. Everyone could read them, but it is evident that very few did.  Accessibility is not just about availability.

I suspect, as so often is the case, that size is everything. We are all busy, few will prioritise a 33 page document that has no clear executive summary, especially with a title of veterinary specialisation; at the time of the report there were around 2500 certificates passed, yet only around 300 RCVS specialists. Its title suggested it was not relevant to the majority. Deep within this document was the question Do you agree that there is a need to simplify the range of qualification titles and postnominal letters that are shown against veterinary surgeons’ names in the RCVS Register? BEVA responded on your behalf and as a result the proposal to only indicate broad areas of work (equine practice) were changed and the advanced practitioner status will now indicate specific areas of work (equine internal medicine, equine surgery, equine reproduction, equine practice). The removal of post nominals from the register remained. 

So what made so many respond to a petition? Why are the numbers of signatories more than half the number of certificate holders (there are less certificate holders than there are certificates passed as some have multiples)? It is clearly all about methods of communication; news of this petition spread by social media, by online forums and via email. Short messages, easily digestible, that asked for people to respond to a single question. All that was required was signing a petition, although many have also left comments. Size was everything!

The world has changed, the internet bombards us with information. It has made us good at digesting small bits of information, and shunning long blocks of text. Twitter and text messages limit us to 140 characters, we have grown use to this. Many of us are disinterested in emails that are longer than one screen, irrespective of the device! Short IS sweet. The RCVS need to wake up to this new reality and be more concise in its communications. If they want engagement, then they need to develop ways to encourage this in a way that is relevant to the 21st century. If they don't they are going to be faced with a great many more 11th hour petitions and resentful members. 

Many of us were surprised by the response of the college, to review this proposal, to respond to its members! The president even took to Twitter to share the news and engage in debate. Is this a new era in listening from council? Are they living up to the aspiration of 'first rate regulator'? Their response did suggest that the profession has 'misunderstood' the proposals, the same word was used in response to the last petition about out of hours provision. I hope that they have not misunderstood the feeling from the profession on this issue. We DO object to paying £110/year to be listed as advanced practitioners, when listing a certificate has cost nothing, but the biggest objection is to these qualifications being removed from the register. In the words of Jesse J 'Its not about the money.' If the outcome of the RCVS review in June is to simply reduce the costs of the list they will demonstrate that nothing has changed in terms of their ability to respond to the membership. If they review the whole proposal they will show that we really are entering a new era of dialogue and engagement. 

What was interesting in this online debate was the lack of involvement from the BVA. No comments, no tweets, nothing. While BEVA helped spread details of the petition, BVA clearly showed no interest. They did create an entry in their community pages, but this was the day after the RCVS announced their review. It never made it to the Vet Record. This is an organisation that is meant to represent the profession, who appeared to not notice until the RCVS issued a press release. They need to be careful, if the RCVS are going to engage directly with the membership then the BVAs role as conduit for the profession to lobby the RCVS will be lost. People may start asking what us the point of the BVA.....