When does a vet need to perform a physical exam? What if another vet in my practice already performed an exam?

It’s a common question I get at Law and Ethics education seminars, from small animal vets.  The idea that one veterinarian can rely upon another vet’s exam in order to create the veterinary – owner- patient relationship. Normally it’s phrased like “If my relief vet sees a patient while I am gone, can’t I look at the notes and then prescribe a medication?” or “If one doctor does an exam, and then I look at the labs, why can’t I provide a diagnosis to the client?” And I get the underlying concern, that we all want to leverage the multi-doctor practice advantage, or use the relief vet to the fullest. And many vets don’t want to ask a client to come back into the same practice again, since they’ve already seen a different veterinarian recently.  But waiving the requirement to establish a vet-owner-patient relationship through physical exam of the patient…it’s just not a good idea.

In Georgia, the Veterinary Medical Board thought this item was so important, they updated the practice act to clarify what’s needed to practice medicine on a patient.

In 700-8 -01, of the Georgia Code,  in relevant portions states  “An appropriate veterinarian/client/patient relationship will exist when…the veterinarian is personally acquainted with the keeping and care of the animal(s) by virtue of an examination of the animal by the veterinarian within the last twelve (12) months….A veterinarian/client/patient relationship cannot be established solely by telephone, computer or other electronic means.

(Now before I continue, I should not that there is an exception for herd/food animals.  I’m not going to talk about that here though. This blog is related primarily to our typical small animal vet.)

Basically, you have to have seen the animal in the last twelve months to perform veterinary medicine for that patient. And some veterinarians seem to blow this out of proportion, that it somehow defeats the whole purpose of using a relief vet or of establishing a multi-vet practice.

The key here is to focus on what you can and should do.  If you’ve seen the animal before, in the last 12 months, then if a relief vet covers for that existing owner and patient for the weekend, performing an exam,  you still have an independent vet/owner/patient relationship. Just because another vet looked at the animal, it doesn’t remove your relationship unless the client no longer agrees to follow your direction for the care of the animal. So in this case, we’d look at the records, recall what we know of the animal, and proceed. The requirement for an exam is still once per 12 months. There were be circumstances when you’ll want a recheck or for the animal to come in, but the limit is 12 months.

This covers 80% of the cases in our clinic, and should for most other small animal veterinarians as well. But here are the more uncommon scenarios:

  1. It’s an existing owner/patient you haven’t seen in the last year.  If that’s the case, then make certain your associate, relief vet, reception, assistants… i.e. somebody, warns the client that if they only see the relief vet for an exam, they may have to come back in for an exam and recheck before another vet can see them. This is to establish the vet-owner-patient relationship, and to ensure that owners and patients get the best medicine, rather than just diagnosis by phone or reading.
  2. It’s a new client, that the other vets in the practice or only the relief vet has seen. In this case, the obligation is clear. Before a vet intervenes with a patient that another vet has taken the time to examine and treat, make certain you have established the vet-owner- patient relationship. An under most state veterinary practice acts, one element of establishing this relationship is the physical exam of the patient.

Look, I get that it’s a hassle, and that clients are unhappy at the prospect of what they see as a duplicate exam. But the practice of veterinary medicine is regulated in order to protect the public. And in most cases, the standards for the practice of veterinary medicine are there for a good reason.

I recall a telemedicine call with a human doctor when I had pain in my side, and they thought it might be kidney stones. The symptoms were all there. But when I came in, it turned out that I had shingles, and a simple physical exam confirmed it.  The exam provided additional information that helped provide a proper diagnosis. The number of times people have called in with incomplete or incorrect information about pet “emergencies” that we were able to correct with a physical exam are too numerous to count. Vets are the professionals, and generally have more experience and expertise to be able to correctly identify physical symptoms than pet owners.

This is better for everyone, including the owner, who may grumble about the time, hassle, and expense of another exam, but will file a complaint for malpractice in a heartbeat if you miss something because you didn’t do an exam. I have heard, more than once, the question from angry or grieving clients “why didn’t you (vet) see that?” Without the physical exam, or a knowledge of the animal from a physical exam in the past 12 months, you’ve got very little to defend yourself with.

But there is something that makes this a little easier, with proper planning and communication. And that’s the fact that one vet (at least) has established a vet-owner-patient relationship.

If the vet that saw the animal has left follow-up instructions, such as refills or contingent additional treatment instructions…. following those instructions does not create the need for a new vet-owner-patient relationship for another vet. And if something changes, you can call the vet with the relationship for additional guidance, if it’s appropriate for indirect supervision. Why? Because they, the first vet,  *still has* the vet-owner-patient relationship for another 11+ months after the exam. They can still practice appropriate veterinary medicine in relation to their patient.

For example, if Lydia is a relief vet, and prescribes an antibiotic for a dog at your clinic, with two refills set for the next two months.  The refill is still at the direction of the veterinarian that performed the exam, diagnosis, and has the vet-owner-patient relationship.  If the owner calls in for the refill, you don’t need another exam to fill that order. If Lydia also instructed that ‘if dog is painful, then the client can call in and we can provide an anti-inflammatory without a refill. ‘ Again, this is still Lydia, the vet with the existing relationship, and the rules are the same as you use.. ie.. appropriately  indirect supervision for treatment or care of the dog. The fact that a vet is performing indirect supervision while another vet is in the clinic is not material in this case.

But if something changes, or another vet exercises their professional judgement and provides care that requires their own vet-owner-patient relationship, then all bets are off. A physical exam is needed to create the appropriate relationship and authority to practice veterinary medicine on that animal.

So how do we make this easier for a clinic to operationalize?

  1. First, make sure your assistants, techs, receptionists, and vets, are all aware of the need for physical examination for treatment within the last 12 months by each vet to each patient.
  2. Second, make certain your clinic staff don’t confuse that need for a new exam with following the orders of a vet that already has that relationship.
  3. Third, make sure that they inform clients of the potential for another exam, and see if they want to schedule for a day before or after the relief period, or when a vet with the veterinary-owner-patient relationship is available.
  4. Fourth, work on an agreement, with all vets in a multi-vet practice, as well as relief vets, for how to deal with follow-ups to instructions and diagnosis of patients, where the vet on duty has not performed a physical exam in the last 12 months. Answer these basic questions:

Will you be available for follow-up when you are not at the clinic? What type of instructions are in the notes? Are there any contingent instructions? Did you state in the record when your instructions are no longer valid? Will you inform your clients that they may need a new exam with either a relief or an associate vet at your practice while you are not present? Do you have a general policy on your website on when you’ll ask for an exam?

And if you are an associate, make certain your clinic manager is aware when the requirements for physical exams are required as a part of establishing the vet-owner-patient relationship, in order to practice veterinary medicine in relation to that patient.

With proper communication, particularly by staff and the vet that has the relationship with the client, you can avoid a lot of the complaints and frustrations that clients traditionally experience with what they view as unnecessary extra exams and fees.

By explaining why it’s important for good medicine, and for proper diagnosis and treatment of the patient, you can also provide a better customer and patient experience.

And by doing the things above… you’ll also have included some better vet practices.

 

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1 Response to When does a vet need to perform a physical exam? What if another vet in my practice already performed an exam?

  1. Pingback: Using Text Messaging as part of your Veterinary Practice | Better Vet Practices

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