Now this is a particularly interesting comment (IMHO) which points at something we've noticed regarding some of the vets we have had (or seen records from other practices) vs. the way we like to run the practice....You end up with the clients that matches the practice philosophy.
Our approach is that a client comes to us to fix a problem (if possible). We believe the client does not want to come back multiple times to figure it out (sometimes you only get one chance or they will go elsewhere - we have all seen the vet hopppers). So, we believe in appropriately working things up really well as close as you can get to boarded internal medicine level or university w/o being boarded. Of course, we do the medical treatment plans (estimates) and get approval and discuss with the client where they will like end up going down a treatment plan path. Beginning with the end in mind is entirely another topic....
We do the things we are really good at and refer as needed. E.g. all rads go out to be read by Board Certified Radiologists, we have ultrasound and us it, but all call in traveling boarded internal med people for ultrasound, use a very good boarded surgeon in addition to doing our own surgeries. Of course, we like medicine and think it is really interesting and keep learning and always want to be better.
Some vets we have employed and others whose clients bring their records to us, do not seem to want to practice at the level and would like to turf the hard stuff to someone else. It seems that it comes down to a philosophical view of how you want to practice and finding the place that matches you.
Is this a conscious individual choice, as in "I do not want to do all the complex stuff?
Or maybe it is hard to practice at a high level in a GP where no one else cares that much, so you just dumb it down to get along.
You get tired because thinking hard all day long is exhausting (it is we know)
As an ethical doctor, you work up and treat the "hard" stuff as you call it, if the client is given the choice of all options including seeking a specialist's care who can do this particular thing better than you, and they choose to have you continue care. Not because you just want to or because management tells you to.
If you have a good tertiary referral center nearby with radiologists, you should provide that option, because I'm sorry, but a traveling internist just isn't good enough for a lot of things. If you waste your one shot at having the client pursue an ultrasound, and the patient needs further specialized care, or lands in the ER due to decline of the pet, that ultrasound they paid for at your clinic is worth ****.
A number of eye things like acute glaucoma and indolent ulcers are absolutely best managed by an ophthalmologist, and that option should be presented. It'a not that a GP can't manage these things. And sometimes it works well without complications. But you are being a stubborn self righteous dingus unless you at least bring referral up as an option, and don't explain how horribly wrong this could go.
If you don't at least offer a derm referral for the allergy cases that actually want immunotherapy, then you're an dingus. No, it's not the same to just do the blood test and get a commercial injection and follow the schedule. It's sort of an art. What can go wrong? Well if it doesn't work, there's a chance it would have worked with the dermatologist, but you've wasted a ton of the client's money and maybe a year of time, and burned that patient's chance of immunotherapy.
If you have a cat with bad stomatitis, you're an dingus if you don't at least offer referral. Yeah I feel comfortable performing full mouth extractions. But given the relatively high odds of FME not resolving the issue fully, and knowing that I'm more likely to leave small amounts of tooth tissue than a dentist (and we would have to wonder if that happened if kitty doesn't do well), nevermind that a dentist will be able to do it better and faster, I at least have to offer.
Especially if you do not have 24 hr staffing, including a doctor, there are just certain things that you need to at least offer referral.
I do everything for my own pets including emergency surgery if it's something that I can handle, be it foreign body surgery, PU, amputation, placing and managing E-tubes, etc... My pets are collectively as challenging as they come. But the reason why my ancient cat is alive and still kicking comfortably is thanks to the multiple internists, cardiologists, radiologists, criticalists, and dermatologists who have been involved in the meticulous care she requires. My clients at least deserve to be given the options for this level of care. If they don't elect it, that's fine. I'll do whatever is indicated to the best of my abilities. But, there gets to be a point at which it would just be more efficient and sometimes even less costly for the client to just take the referral.
Since we're playing the game of making assumptions, I'll say that usually the "I keep all the complex cases and try never to refer because I'm awesome" hospitals are the dated malpractice-worthy hospitals with hospital managers who have no clue what modern standard of care is. If you don't want people to make that assumption about your hospital (which is kind of legit based on your posts), you should stop doing that to others. Also, no matter how experienced you are, and no matter how much you think you know how doctors think, you haven't a clue. I have a hard and fast rule for what I will tolerate as a doctor. I will not stay at a hospital where non-DVMs have any say in medical decision making. I will also not work where I directly report to a PM. I will only report to a DVM owner or medical director. Perhaps it's your poking your head in where it doesn't belong that strained your relationship with previous DVMs at your practice. I would not tolerate your patronizing attitudes as a DVM in a practice. There are plenty of other jobs out there, where I wouldn't have to deal with such bull****.
