Better Vet Practices

One question which I get quite a bit is related to animals that are “found” or “abandoned.” Typically the person who brings in the animal is incredibly honest that they are not the owner of the animal.

The vet is unable to establish a VCPR or gain consent… without the owner or the agent of the owner, with rare exceptions. Because there is no owner consent, your options are limited.

First, you may, for no fee or reimbursement, provide emergent care through the good Samaritan exception. This means even your supplies must be provided without charge. See earlier posts on this site for more information on Georgia’s good sam law.

Second, if they are in the proper care of a shelter, humane society, or local government agency authorized for the care of found or abandoned animals, you may gain consent from them, as the custodian of the animal. I recommend getting that direction in writing, in case an owner later disputes their authority.

Third, certain state programs, such as the feral cat neuter programs are authorized for animals that do not have owners. Each state program has a statutory authorization you should verify prior to performing veterinary services.

What happens if you don’t? Apart from violation of the practice act and placing your license in jeopardy, there have been a number of legal disputes in this area.

First, neighbors and others may take possession of an owned animal for humane reasons or selfish, without the owners consent. When the owner discovers this, they sue both the unauthorized taker of the animal and the veterinarian. This is very costly, particularly with equine and specialized domestic breeds or training.

Second, particularly for euthanasia, there could be damages associated in a direct suit with an owner, or even civil charges from the agency that has authority over those animals. While it’s most common in the wildlife realm, unclaimed animals are also legally under the power of state and local regulation, and your unauthorized treatment of them, for a fee, can be subject to reprimand, fines, and further legal action.

Third, it’s an ethical issue. Except for immediate life saving care, neither you nor the findee should be making decisions on behalf of the animal or another person without owners consent. This is a fundamental tenet of the privilege to practice veterinary medicine… that your care is always authorized, not forced or done without knowledge of the owner.

While there are volumes of cases on unauthorized medical care in the human realm, as consent laws in the practice of veterinary medicine become more common (in Georgia since 2018), the prevolence of lawsuits and penalties for practice without consent will also continue to increase.

A great question in our Leap session today…

Do I need to exhaust all other approved drugs in order to exercise AMDUCA for off label use in companion animals? No.

From the AMDUCA statute and the FDA guidebook-

In companion (non-food-producing) animals, you can prescribe an approved human drug for an extra-label use even if an approved animal drug is available. This is not the case for food-producing animals. For these animals, FDA’s requirements for extra-label drug use prohibit you from prescribing an approved human drug if there’s a drug approved for food-producing animals that you can prescribe instead. For example, if a drug approved for chickens is available, you must first use that drug to treat a sick cow before reaching for a drug approved for people.

https://www.fda.gov/animal-veterinary/resources-you/ins-and-outs-extra-label-drug-use-animals-resource-veterinarians

After careful reading, it is still the case that particularly for companion animals, you do not have to exhaust FDA approved animal drugs, with a few minor exceptions.

From the guidebook linked above:
“In companion (non-food-producing) animals, you can prescribe an approved human drug for an extra-label use even if an approved animal drug is available.”

In food animal cases this is not the same –
“This is not the case for food-producing animals. For these animals, FDA’s requirements for extra-label drug use prohibit you from prescribing an approved human drug if there’s a drug approved for food-producing animals that you can prescribe instead. For example, if a drug approved for chickens is available, you must first use that drug to treat a sick cow before reaching for a drug approved for people.”

However, even in this case, you need to fulfil only ONE (not all) of the following conditions-

 “…one of the following general conditions must be met before you can legally prescribe an approved human or animal drug for an extra-label use:

• There is no animal drug approved for the intended use; or
• There is an animal drug approved for the intended use, but the approved drug does not contain the active ingredient you need to use; or
• There is an animal drug approved for the intended use, but the approved drug is not in the required dosage form (for example, you need a liquid dosage form, but the approved drug is only available as a tablet dosage form); or
• There is an animal drug approved for the intended use, but the approved drug is not in the required concentration (for example, you need 5 mg, but the approved drug is only available at 50 mg); or
• You have found, in the context of a valid veterinarian-client-patient relationship, that the approved drug is clinically ineffective when used as labeled.“

Note the general companion animal exception of the FDA Guidebook still also applies.

Telemedicine is one of the ways to have social distancing but still provide services during this pandemic. I’ve already received multiple vendors asking for us to spend on advertising for our telemedicine capabilities.  While I am not certain spending more during this time period is the wisest choice, making certain our telemedicine capabilities are ready, and conform to the practice act is important.  Please see my post from last year on telemedicine, or look at the GVMA website for their advice and details.

New article in The Georgia Veterinarian

Using Text Messaging as part of your Veterinary Practice

This year the use of CBD  in veterinary medicine is a hot topic. My fellow member of the Bar, Betsy Choder of Vetcounsel.net wrote a comprehensive article on the topic for the GVMA earlier this year. If you haven’t read it, I highly recommend you do so.

In addition, the FDA has recently published a set of FAQs that every veterinarian should read on the ability to prescribe CBD derived products. Here is the FAQ link – https://www.fda.gov/news-events/public-health-focus/fda-regulation-cannabis-and-cannabis-derived-products-including-cannabidiol-cbd#extralabelanimals.

I’ve spoken on this topic to legislators at the State Capitol earlier this year, and at GVMA sponsored LEAP sessions. I have several more this year where I condense and summarize this information, including how to interpret the FDA guidance in relationship to Georgia’s Practice Act.

This topic is developing, so I recommend checking with the FDA site regularly to see if there are updates.

At a recent LEAP, I was asked what the requirements were for prescribing antibiotics to Bees. And lo and behold… there is a federal government site to answer part of this question.  The FDA has permitted no less than 11 substances to be prescribed by a veterinarian in a bee feed directive.  Here is the link – https://www.fda.gov/animal-veterinary/development-approval-process/using-medically-important-antimicrobials-bees-questions-and-answers

Now, they don’t answer all the questions for veterinarians in Georgia… but here’s the basic requirements. You should read the full text from the FDA prior to prescribing.

1. The Licensed Veterinarian must diagnose the condition and issue an appropriate RX or VFD.
2.  The veterinarian must establish a valid VCPR
3.  The veterinarian must retain a copy of the VFD for at least 2 years, in its original format.
4. And in the case of issuing a VFD or RX for hives… to establish the VCPR, the vet will likely have to make visits to the facility where patient(s) are managed. Under GA law, that is at least once a year.
5.  The minimum standard of care must be followed, such that the veterinarian has sufficient knowledge to initiate an preliminary diagnosis… and that likely means enough medical knowledge of bees and their health to make a diagnosis.

Whether it is cats, exotics, poultry, bees, or any other animal, the most important thing before considering how to care for an animal is ensuring that you have enough knowledge and skill to create the initial diagnosis for that animal. So in addition to the FDA requirements, always remember the first part of the VCPR is that the veterinarian assumes responsibility for making medical judgements for the animal. That’s solely the veterinarian’s option.

In any event, I hope this information is helpful… let’s get better together!

There’s been a lot of questions lately that have come in regarding which licensed professionals are able to perform surgeries on dogs and cats.  The short answer is… no they may not under current Georgia law.

There are a few exceptions below, but none of those apply to recently reported cases such as the recent controversy in Atlanta. In spite of the clear restriction by Georgia State Code, it has remained a hot topic in the press (such as the Atlanta Journal Constitution), tv news shorts, and reddit.

I’ll go over the boring (or exciting depending upon your viewpoint) legal analysis which is unsurprisingly straightforward.  As you know I was a part of the legislative activity of the latest practice act, and along with Betsy Choder, recommended some of the language that eventually made its way into the bill and law.  Chapter 50 of Title 43 of the Official Georgia code is called the “Georgia Veterinary Practice Act.”   It states that the practice of veterinary medicine includes “surgery” in Section 3.25.  Unsurprisingly, only licensed veterinarians are permitted to perform veterinary medicine, as it states in Section 30…” No person may practice veterinary medicine in this state who is not a licensed veterinarian or the holder of a valid temporary license.”  And adding emphasis, Section 45 states that “ It shall be unlawful for any person to practice veterinary medicine without a valid license.”

Simple logic here indicates that since a human medical doctor does not defacto have a valid veterinary license, they are engaged in an unlawful act if they perform surgery on an animal, which is veterinary medicine.  Not so fast…

There are a few exceptions in Section 40 of the act, some of which permit surgery by a non-veterinarian on an animal in a set of very limited circumstances:

1. Federal, State, or local Government employees or contractors, for the sole purpose of “control of stray animals.”
2.  Employees of a college or university performing their duties on animals owned by such institution.
3. Vet students as part of supervised eduction, and similarly veterinary school faculty, and some foreign or out of state licensed veterinarians subject to licensed veterinary supervision.
4.  Livestock and food animal exceptions (while important, these exceptions do not apply to dogs and cats)
5. Scientific research, subject to complying with federal, state, and local laws
6. Accredited Zoo Animal care, Aquaculture, Farriers, and some others, none of which relate to dogs and cats.

In addiont, there are a couple of unusual exceptions, cited by media or people performing veterinary medicine without a license, that require more detail –

First, there is a good samartian exception for care rendered at the scene without fee or gratuity, as outlined in Article 4 of the Act.

Animal Shelters –

Section 8 A of the Act states  that some acts may be done with licensed kennels, animal rescues, pet-sitting, and boarding… however this exception expressly rejects surgery (bold below).

Any person acting under the direct or indirect supervision of a licensed veterinarian to provide care to animals that are the property of an animal shelter when at least the following three conditions are met:

(i)  The person is an employee of an animal shelter or a local government who has control over the governance of the animal shelter;

(ii)  The person is performing these tasks in compliance with a written protocol developed in consultation with a licensed veterinarian; and

(iii)  The person has received proper training; provided, however, that such persons shall not diagnose, prescribe, dispense, or perform surgery.

Non Veterinary licensed parties-

Section 13 states that:

 Any other licensed or registered health care provider utilizing his or her special skills, or any person whose expertise, in the opinion of the veterinarian licensed in this state, would benefit the animal, so long as the treatment of the animal is under the direction of a licensed veterinarian with a valid veterinary-client-animal patient relationship.

Now here we have some vagueness… in that someone may argue that surgery is a “special skill” or “expertise”… however the act later states anyone who is delegated a task is considered  a Veterinary Assistant. “‘Veterinary assistant’ means a person who engages has been delegated by a licensed veterinarian to engage in certain aspects of the practice of veterinary technology but is not registered licensed by the board for such purpose”

And Section 27 of the definitions states that Veterinary Assistants MAY NOT PERFORM SURGERY…

“‘Practice veterinary technology’ or ‘veterinary technology’ means: (A)  To perform animal patient care or other services that require a technical understanding of veterinary medicine by a licensed veterinary technician on the basis of written or oral instruction of a licensed veterinarian, excluding diagnosing, prognosing, performing surgery, prescribing, or dispensing…”  and again in Section 61 – “No veterinary assistant shall make a diagnosis or prognosis, prescribe treatment, perform surgery… “

So there’s no express permission or exception within the Act that permits a licensed human medical practicioner to perform surgeries on dogs and cats, unless they are  goverment employees or contractors for animal control, are related in very specific ways to colleges and universities, are licensed veterinarians outside of the state of Georgia (under licensed veterinary supervision), or are performing a regulated scientific research study.

So now that we have clear regulations that prohibit this behavior, what is the consequence?   First, the Board of Veterinary Medicine has the duty to enforce the act. It appears that to date they have not engaged in actions to prohibit or enforce the act against some of these non-licensed veterinarians. I should point out that not all actions of the board of public, they have the ability to take some non-public actions, and that investigations may be ongoing. However, I have seen a letter in the coverage linked above where it appears the Board of Veterinary Medicine was in error in their legal analysis of the act and what it permits.

Nevertheless, there are other consequences which may still apply to medical practicioners performing veterinary medicine upon domestic dogs and cats.

First, licensed veterinarians, performing veterinary medicine above the minimum standard of care with a valid VCPR (“the authorized practice of veterinary medicine”)are immune from charges and claims of animal cruelty (Title 16, Chapter 12, Section 4). There is no similar shield for other professionals. They are open to civil and criminal charges in their conduct. It is one of the items I’ve spent a fair amount of time describing, in that one of the important reasons to provide the highest level of care and pay attention to the practice act and a valid VCPR is to protect oneself and staff from third party claims of animal cruelty.  And it’s unclear if a human medical insurance policy or shelter policy would cover civil and criminal procedings and penalties for the unlicensed practice of veterinary medicine.

My general legal advice is to let licensed veterinarians, who have invested years of training, continuing education, tools, and experience, practice their profession on animals, and let human medical practicioners keep their practices to humans. If not, it may take only a single clever litigator or prosecutor to ruin the lives of even the most good hearted non-veterinarian.

Hi All,

I apologize, but I’ve been unable to respond to most posts and questions over the past couple of months due to an accident. While it’s unrelated to the practice of veterinary medicine or legal issues, it does bring up an important point to consider-

Do you have a succession plan?

Do you have a set of instructions for your successor should they need to take care of your duties? Is it documented? Does your successor know where it is?

We have a set of colored binders for succession instructions, that lists the primary contacts and tasks that have to be performed while the practice manager and chief veterinarian is out, for any reason.  I highly recommend it to you as well.

Here’s a short video on my accident, if interested. To the GVMA, our clinic, and those who prayed and helped.  Thank you!

There are four new posts I need to get out to you in my absence, including the AVMA Committee meeting on the VCPR this fall, the proposed amendment to the Practice act, the changing of names for RVT/LVTs to “Veterinary Nurses” (which I support), and THC/Cannabis usage.  In addition, there have been some interesting questions recently posed on referral clinic arrangements and mobile clinic record keeping. All in all it is already a very interesting year.

Thank you all for viewing and let’s get better together!

-Don

During the Leap presentations at the GVMA Fall Convention, I had several questions on what information needs to be included in a veterinary record.  The Georgia Board of Veterinary Medicine has given us a list in their Rules – Section 700-8-01 (c), Unprofessional Conduct. Please note that this is the list of what should be included, but is not limited to this information, as the Board rule specifies that information sufficient to justify the diagnosis and warrant treatment must be included, even if that information is not one of the items on this list. However, you *shall* have all of these items, according to the state board rules, which are referenced and empowered by the Veterinary Practice Act.  Take a look and see if it’s time to update or expand what’s in your medical records for clients…

(c) Failure to Maintain Patient Records:

This Sunday I’ll be speaking again, on the new practice act, at the GVMA Fall Convention.

Click here to register for the GVMA Fall Convention – October 19 – 21, 2018 – Atlanta Marriott Century Center

This marks the fifth LEAP event this year, including my favorite LEAP co-presentation with Dr. Beckey Malphus at Thomasville this August.

I spoke on Dog Law in Northern Georgia in Young Harris at a beautiful location. Great questions!

And earlier this year I spoke at UGA and in Savannah on the practice act and recent changes.

It’s hard to top the beautiful beaches at San Destin, where I spoke for over 5 hours at the Emerald Coast Veterinary Conference this year as well.

All in all, this was the best year for veterinary law and ethics education yet!

Looking forward to the last couple LEAP presentations, I’ll post more details as they get closer.