VCPR, veterinary consolidation, and subsidized medicine: Your opinion matters

Commenting Period Open Make Your Voice HeardShould the Veterinarian-Client-Patient Relationship (VCPR) be one-size-fits-all? Will veterinary medicine thrive in the age of national practices? How do you feel about subsidized veterinary care?

These are critical issues facing our profession, and they may affect how you deliver services to your patients and clients. And we want your input to help guide us in addressing them.

The AVMA House of Delegates will debate these topics at its upcoming Veterinary Information Forum during the annual Veterinary Leadership Conference in January. As an AVMA member, you should have recently received an email from your delegate asking you to provide comments on these topics so that your opinions can help us shape our discussions and actions.

The specific topics for discussion include:

  • National veterinary practices: Consolidation and nationalization present veterinarians with unique opportunities and challenges, and likely will have a significant impact on national, state and allied veterinary associations.
  • Delivery of care by not-for-profits: What are the opportunities and challenges presented by the delivery of subsidized veterinary care? Does this type of service impact the public perception of veterinary medicine?
  • Defining the Veterinarian-Client-Patient Relationship: Should species, practice type, and location impact how the VCPR is defined? How does the FDA definition of VCPR impact veterinarians? The discussion will provide guidance to the AVMA Task Force on Model Veterinary Practice Act.

Your opinions matter to us, and they will guide our discussions. Let your voice be heard, and be part of the conversation. We encourage all AVMA members to take a few minutes to review all of the issues on the HOD agenda, and to contact your delegate to share your thoughts on these issues before the meeting. It’s easy to connect directly with your delegate online through our website, or you can respond to your delegate from the email that was sent to you last week.

27 thoughts on “VCPR, veterinary consolidation, and subsidized medicine: Your opinion matters

  1. Here are comments from Michigan Veterinarians that were emailed to Michigan’s AVMA Delegates:

    National Veterinary Practices from John Kolenda
    I consolidated my practice 4 years ago with a national chain. It seemed to be the most logical thing to do with a large 5 Dr. practice. So far so good. Dr. K

    General Comment from Marlin Kleckner
    As a long retired veterinarian, I will not offer my opinions. However, I admire your attempt to get feed back from you constituents!

    Delivery of Care by Not-for-Profits from Phillip Gill
    I do think we need something in place to help those at poverty level. All DVMs get frustrated when clients cannot afford the care an animal needs to be healthy. We’ve all had to euthanize pets that were in pain, but could not be treated due to cost.
    A funded organization similar to Govt run Health Depts would be useful.

    National Veterinary Practices from Phillip Gill
    We do realize that a DVM-client-patient bond is important and that will never come from a National Vet hospital. We will always need to private clinics for clients to feel comfortable. The trust in a DVM still remains very high and we are needed more than ever to diffuse misinformation on the internet. A public mega-hospital cannot create a relationship with a client – we’ve seen this already on the human side.

    VCPR from Phillip Gill
    Even though clients sometimes want to treat their pets like kids – we have to remember they are not. We need to still keep strong caps on lawsuits especially. If we do not, our insurance costs will skyrocket and only the richest clients would be able to afford our services. Unlike human medicine, I feel we self regulate very well and are always looking to remove those few individuals who are actually practicing inappropriately. I feel more often than not, most case failures are due to clients not complying with treatments and follow-ups rather than DVM misdiagnosis.

    VCPR from Richelle Smith
    The VCPR should be written, upheld and adhered to as the highest standard standard of care. It should be strongly worded to protect veterinarians, clients AND patients.

    Delivery of Care by Not-for-Profits from Richelle Smith
    Opportunities? None for a veterinarian looking to practice high quality medicine. The only way subsidized care is beneficial to the general population is when it is limited to those with true and defined actual need. When it is marketed to the general population as “affordable” veterinary care (i.e. it’s the SAME care your pet would receive at a regular veterinarian – which it isn’t – but at an “affordable” cost – read: you’re regular veterinarian is ripping you off – it ABSOLUTELY impacts the public perception of veterinarians and defines the race to the bottom that seems to be consuming so many right now.

    National Veterinary Practices from Richelle Smith
    Overall, the takeover of veterinary practices by corporations will be a losing situation for veterinarians. Corporations, as a rule, have their bottom line as their primary motivation. NOT the well-being of the doctors, technicians, and (least of all) the patients themselves.

    Comment on Resolution 1 from Alex P. Imlay
    Please defend the right of pet owners and their veterinarians to
    determine what is best for each family. Governments should never be
    involved in private decisions about health care, surgery, and or
    husbandry. Please condemn actions by government entities to limit our
    abilities to practice. Please leave resolution 1 unchanged.

  2. Thank you, colleagues, for sharing your insightful and thoughtful comments related to the topics we will be discussing at the upcoming Veterinary Information Forum as part of our annual Veterinary Leadership Conference. Your delegates, and the AVMA, consider your input critical to addressing some of the most pressing issues in the veterinary profession. This type of member engagement with your national association will continue to make the AVMA the voice of the profession. It helps us continue to evolve in a changing world as we strive to protect, promote and advance a diverse community of veterinarians with unique perspectives.

    Sincerely,
    Dr. Doug Kratt, House Advisory Committee Chair
    Dr. Michael Whitehair, Board of Directors Chair

  3. I have been a small animal vet in solo practice for over 30 years. I am not a fan of the chains. They all seem to offer cookbook medicine that can not be altered. There is no plan b or c. Only the most expensive all inclusive plan a. I’m a big believer in vaccines but tailored to the individual pet. Animal I see from banfield are all given every vaccine available. I also feel that new grads are not flexible in their treatment plans. They too want to only offer plan a. The world is not made up of one kind of client. Not evey pet is able to get the best treatment but still deserves our care at the best level we can offer. I too worry that some day practices like mine will disappear. I don’t like corporate medicine in human or veterinary medicine. And I don’t think it’s made the world better.

    • I too have been in practice for over 30 years and also agree that students are NOT taught care and compassion for the pet owner. Why is it negligence for a pet owner to not fix a fractured leg but necrotic dentition or abscessation form chronic ear infections are not deemed horrendously neglectful? Actually plan A or what ever is often the best choice for all especially the pet…being the most thorough is often the most expensive. ie..debride that laceration not just clip and clean and give antibiotics. BUT I get so sick of our local specialty practices telling clients that if they do not allow the thousands of dollars of medical care to occur their pet will suffer horribly and that is just not always the case. I have seen too many euthanized because they were not offered a plan B or C. I am very successful and still practice great quality medicine but I tailor care to steps when requested and explain why sometimes steps are the wrong choice. Honesty and hardwork are the dying commodity. The bain of our existence is NOT the Banfields or the corporate emergency clinics, it is ourselves..GONE are the hardworking vets that were on call at least a day or two a week..that only had one or two colleagues with them and they knew everyone by first name. We have stopped caring about our profession and are self obsessed with worrying about compassion fatigue and our balanced life. I have traveled extensively, ski ride horses, am a loving mom and grandma and I still put in long hours whichmy family is very supportive of. In the old days the kids followed in your footsteps! I have been doing this for years and love it every day of my life! The continued learning the improvements in care fascinate me to grow with the profession. I try to out smart the internet not feel threatened by it. It is us that are failing the profession. . I am sure I am going to get a lot of flack for this but do not fear change, embrace it or rise against it like the little book stores did and are winning along with the little coffee shop down the road. I can’t ride my horses through the local fields anymore so I find new trails to go in that are better……

      • I don’t think you can be taught care, compassion, empathy, etc. You either have it or you don’t.

    • I agree with you on the corporate issue. It will jack up the price of vet med so high that people will HAVE to get insurance…or go to us little guys. I see a dark cloud over our profession if veterinarians end up prostitutes for insurance companies and then big pharma. I am also a solo practitioner in a rural area. The gold standard of care is way beyond my means. Fortunately, I think about what is going on with my patient. I can refer if needed but that’s all I think the corporates will be good for…referrals.

  4. I am against the national vet corporations like Banfield. It is my opinion that they take away the individual doctor’s ability to analyze cases and make decisions based on their clinical judgement by replacing them with guidelines, policies, and procedures. I worry that individual practices will disappear and be replaced by chains, and that veterinary medicine will follow the path human medicine has taken into regulations and rules that impede patient care.

    Subsidized veterinary care is a necessary part of veterinary medicine at this point in time. Unfortunately, the combination of limited financial resources of owners and limited time per patient due to high case volume can cause quality of records and care to suffer, but without these services, there is a portion of the pet population that would not receive any veterinary care.

  5. I am a DVM with 3 years post grad internship and residency, 30 years in private practice and 7 in a non-profit state humane agency. I wrote the gist of what follows to my reps, allowing me to (too easily ) to expand. .

    NATIONAL VETERINARY PRACTICES. The biggest problem is in an employment dispute with corporations, an individual veterinarian is at a big disadvantage in a law suit. At best, even when corps are clearly in the wrong, mediation and settlements come with a confidentiality clause – and- esp. this year, it is clear, this is not problematic, it is clearly unfair to the aggrieved. This not only keeps others from knowing which corporations are acting despicably, but the veterinarian cannot explain why they left, with an inevitably damaged reputation. Add to this, veterinary practice is still a relatively small market. So if a corporation owns 8-10 practices within 50 miles- one could become unemployable— making any settlement for lost wages a joke. I do see some reports about unions – maybe that would help.

    Because I have OCD in a state with antiquated Rabies vaccination rules and requirements, I have had to tangle with primarily, PetCo / VetCo and Banfield, over rabies certificates. When large purveyors of veterinary medicine, cannot will not – reissue a rabies certificate, correcting an obvious, provable mistake or misprint – because the DVM who no longer works for them, can’t personally correct and sign it, is sublimely ridiculous. It should be, illegal.

    Delivery of Care by Not-for-Profits: : I see the demand increasing as the middle class becomes the lower class in the age of Trump. 80% of Americans live paycheck to paycheck . Our profession is exacerbating the problem. In the laudable pursuit of high “standards of care “ we are not offering a range of choices. I personally don’t think everyone has a right to a pet-it is a luxury /privilege, and if a pet needs very expensive care to be minimally comfortable – I have no problem euthanizing.

    The profession should not define only the currently accepted, most extensive, invasive, care as the highest standard and therefore only acceptable, failing to consider THERE IS NO RIGHT FOR ALL CASES. It is illegal to guarantee a cure, because -you can’t ! Fools, idiots, and bombastic f moron leaders say “everyone…always.. believe me” and promise doing X results in positive results and doing Z, or nothing = the animal dies. Any level of care below (again, current, dictated) ‘gold standard’ should not by definition, be deemed inadequate, or poor care. ‘Doctors Without Borders’ ‘Operation Smile’ don’t treat patients exactly the same as they would when back at Mayo Clinic. I left veterinary school imbued with the philosophy there are, at any point in time, A, B, C choices to offer a client – and one of those is referral to others who may know there is a an additional choice between A and B. And, I was not to either offer, or acquiesce to doing, D or F.

    We are not catching up to human medicine, we are falling further behind. They look at huge numbers, and when they find that, say, mammograms yearly for under age 50 result in more morbidity and mortality than every 2 years -they change their recommendations. We either don’t want to change, so as not to look like we were stupid-vs. we now know more, or we (and here board certified specialist bear the most guilt) are dishonest by not informing clients the small numbers recommendations are based on. Physicians increasingly consider ‘watchful wait’ and ‘above all do no harm’ and – try to listen to the patient’s expectations and desires. We veterinarians do need to help clients understand when their desires may not be the ‘best’ or most humane, for ‘the patents’.and accept and not lay guilt trips on the many who can afford X Y or Z. Atul Gawande’s Being Mortal should be a must read.

    Many of our recs on preventative care- esp. as regards to routine blood screening are excessive, and turn people off – and worst of all, 90% of the time when an abnormality is found, its ignored or missed! American children, adolescents, adults, who appear healthy, may never have “routine baseline lab work” drawn ! (Take that back, depressingly pediatric academies are recommending cholesterol screening age 7-8).

    All of this pressure drives people to not-for-profits or sliding scale ‘low-cost” facilities. As I discuss below, a full, carefully obtained, history gives the diagnosis, or narrows the differential greatly, in 90% of cases – this is a conundrum for for-profits, because it doesn’t generate income. But because this is this relatively low cost — where non-profits should shine – but they don’t. It costs, but not a lot, to append a differential list with – what would follow (i.e. if a biopsy of an invasive tumor is Thiscarcinoma vs Thatadenocarcinoma, it will alter the prognosis after surgery and radiation or chemo, none of which the client can afford) .

    Defining the Veterinarian-Client-Patient Relationship: Should species, practice type, and location impact how the VCPR is defined? How does the FDA definition of VCPR impact veterinarians? The discussion will provide guidance to the Task Force on Model Veterinary Practice Act.

    Yes, of course. Species is a major factor, when speaking about herds. For both herds, and for individual patients – minimum is exam/evaluation once a year . Situation needs to be taken into account when discussing medical record standards, and documentations.

    At this point this maybe devolving into a rant.

    As someone with an interest in medical records, and POMR, computerized records as they exist and are increasingly used, are hurting patient care (and as a patient who has access to my medical records -extend that to humans) . Form questions, limited response choices, canned client /patient notations can limit the scope of what in some ways is a detective mystery. This results in voluminous, worthless records. Here again Banfield is the worst offender – I have gotten 20 pages from Banfield – I will put a single slash over repeat discharge/caveats -come-ons- and end up with less than one page of real medical record . Perhaps the worst aspect — no choice of not examined = false information.

    I am beginning to wonder if any DVMs reread their own patients’ old records when seeing again. (If the pet was seen 3 times from 6 to 8 months ago for a bad dermatitis — isn’t that worth a update comment? confirmation that it now looks normal, what changed in the last 6 months ). They/we rarely take a history at all, much less detailed. No computer software programs have updateable problem lists or any way to easily to follow a specific problem .
    A full, carefully obtained, history gives the diagnosis, or narrows the differential greatly, in 90% of cases – yet it doesn’t generate income – the same problem is seen in human medicine. There has to be a way to address this fairly for the professional, and the patient.

    I see increasingly the largest problem at least for small animal medicine (and equine) is philosophical- ethical – practical. I can accept that some feel it antithetical to their beliefs, but- like weird religions, I can’t understand or support it. Perhaps I see this more than others, but I disgusted and frustrated with the holier than thou attitude of can’t, or won’t , euthanize any “healthy” animal, or any with a treatable problem, no matter how involved, expensive, difficult that treatment may be. The hubris of DVMs dictating to an owner of an aggressive, dangerous, young healthy dog (well, yah, if they were sick the problem would be self-limiting) they have to have neutered and employ a trainer for how ever long it takes, is unfathomable. Telling clients they HAVE to: find another home for grandmother’s painfully shy and nasty, 10 year old cat; put up with their house being urine soaked and risk life and limb attempting to medicate a recalcitrant cat. Refusing to euthanize a middle aged dog with Cushing’s which is no longer able to maintain housebreaking, or a diabetic, I find astounding – and cruel! Do they not realize the local HS, if space is available, doesn’t have a list of people waiting to adopt high maintenance pets? If they inhabit this moral high-ground– they should have these animals turned over to them, and adopt out from their hospitals.

    And although this may not strictly be part of this discussion, increasingly graduating veterinarians don’t see themselves as medical professionals. I extend this to physicians. When I had a major problem, I chose the emergency room of the hospital my MDs have privilege’s at. For my dying parent, and myself – I didn’t / don’t want a ‘hospitalist’. Medical professionals don’t say “It’s not my case” just because they didn’t exclusively care for the pet (which is the expected result when there is no thought of coming for 30 minutes on their day off) . That is – a job- which deserves respect, but not the elevated respect given to a true professional.

  6. I am 81 years of age and am not in veterinary practice.
    My neighbors complain to me about the following:
    1. “I go to my local veterinarian, love him/her, want the care at that hospital….but when my animal is ill at night or weekend or holiday….they push me to ‘anemerge or whatever emergency hospital’…..I hate going there and the cost and service are not comparable.
    2. My veterinarian is very expensive.

    While I realize that this is how human medicine has evolved, it does not make it right.

    As to ‘Socialized Veterinary Medicine’…..I think that veterinarians in general have ALWAYS given care to animals they knew would be unpaid. Is this not the case these days? Refusing care would seem to be a bad idea?

    The problem is that many programs that begin as a great idea are miss used and advantage is taken resulting in abuse bigtime.

    norman b guilloud, DVM

  7. I have a lot of concerns about start-up house call practices like Vetted- where non- veterinarians get 3 million in start-up money and the owners are interested in money and greed over quality services.

    I have concwrns that the national chains will have too much representation and be without checks and balances in regards to AVMA delegates.

  8. As a veterinarian who works for a non-profit providing high quality, low cost care to income qualified owners, I can assure you that this is an extremely important and much needed service. 23 million pets in this country live in low-income households and I believe that every pet, regardless of the income of their owners deserves high quality veterinary care. Many non-profits providing subsidized care are criticized because they do not income qualify, and I think that criticism is valid. Without income qualification non-profits can not assure their donors that their contributions are being spent efficiently to provide care to the owners and pets that are in greatest need of assistance. And just as importantly, without income qualification we can not assure our colleagues that we are not competing with private practices for their clients. It has been my experience that low income pet owners are just like you and me, they love their pets and they try very hard to provide them a good home. As veterinarians, we would not be living up to our oath if we did not try to help those owners and pets who truly need help.

    • I would caution people to do their homework and know that” non-profit” is not the same thing as “Not-for -profit”. Some of the largest charities for people that are “Non-profit” still pay their CEO’s etc. ridiculous amounts of money. Non-profit sounds noble and all but it implies people are working for little to nothing when in reality they make just as much money or more than regular practices.

  9. I have been in veterinary practice for 36 years. I started in a small town practice in 1981 which was a blue collar town making furniture and textiles to support that industry. The white collar residents were mill owners. So very little middle class. I learned much from the practice owner who graduated UGA as the top small animal student and who valued high quality practice but adapted to economic constraints for the diverse clientele. I was lucky to experience both ends of the practice spectrum, those that could afford all and those that needed an alternative that would give their pets a chance at a quality life.
    My career moved to a more affluent city with evolving referral options including a fledgling veterinary school. The practice was high volume, 3 locations, ER service and I now was practicing where money was not so much an issue. But I retained the individual client and patient care approach I had learned in my first practice experience. We were very briefly involved with the first Pet Smart practice in our county, and the brief nature was ER services which we quickly ended as we saw how they managed patient care. It wasn’t a dismissal of that approach as some client prefer it but it wasn’t consistent with our philosophy of each patient and client is unique and “cook book” medicine wasn’t our philosophy. I’ll say after 25 years in the practice I exited quietly when it was sold to a corporate group. I’ll blame the Pet Smart experience for my exit:).
    In have subsequently taken my surgical interests and skills to low cost spay neuter. Initially I would correct the non profit label. Most are not for profit which means they aren’t government subsidized but backed by a non profit foundation. Do our clients at times qualify for public assistance? Yes they do. But the clinic doesn’t benefit in any way. Our fees are the same despite who pays them. We do spay/neuter, Rabies vaccine as required by law and micro chips. No other services are offered and when we see patients that need more care we refer to local hospitals for that. Do we have people who can afford full service care exploit what we do, sure. But I think they’re in the minority. We have down 66,000 low cost spays and neuters in the 10 years of operation. I hope we have made a difference in the burdens that rescue groups and shelters bear with managing unwanted pets and strays.
    I hope my thoughts on consolidation of veterinary practice under corporate umbrellas are obvious and also thoughts about low cost spay neuter clinics. The former issue, the new generation of veterinarians will need to address. I assume Mars will soon own a major distributor and a veterinary school. Unless I miss my guess.
    The profession has always been made up of fiercely independent people with a common goal; provide quality service individually tailored to patient and client needs, case by case. I hope these kids take that back and pay it forward.

  10. Let the market decide in which direction veterinary.medicine goes. Obstruction to change in areas such as telemedicine is not only harmful to our profession from a public relations standpoint but it also prevents individuals that can’t afford veterinary care from receiving it. How do we explain to our clients why they can receive virtual care and we as a profession cannot? Change is coming and we can be part of it and manage it or we can obstruct it. Our status in the community as caring pet professionals has been eroding over the years and appearing to protect ourselves from the eventual changing market environment will only continue to enhance our image as greedy pet care providers. WE must embrace change and learn news ways to provide care or we are destined to follow the human model of outpatient clinics and specialty centers..VCPR should evolve and not be an excuse for obstructionism !!

    • I heartily agree with Dr Hall. Telehealth (live video interaction between pet owners and DVMs) is happening and is spreading. Does anyone else see that this is the 21st century way to bring the underserved pet population into our sphere? The elephant in the room is, will unscrupulous practitioners diagnose and prescribe for these pets, bypassing brick and mortar practices? I don’t see this happening to any great extent. But regulation of this activity is incumbent on veterinary medical boards. Buckle your seat belts, because here it comes.

  11. National practices will have an impact on the delegates to the AVMA. With so many corporate practices in a state, they can easily pack the AVMA delegates and the rules and laws they pass to conform to what will be profitable for the national practice. Also, national practices make it harder for individual graduates to own a private practice.

    Subsidized or not for profit veterinary care should not happen. There should be no third party supporting vet practices. There is always a price to pay for such arrangements. The entity providing the subsidy can dictate how the practice operates. As with subsidized medical care, there is the huge potential for abuse and fraud with the program which would give veterinarians a bad name. Most of the practices do a great deal of charity work as it is. Shelters have veterinarians already who help them. My practice did a lot of wildlife rehab. All clergy got free services, subsidized by me. I didn’t have to overcharge another entity to provide them. Takes away the entrepreneurial spirit of the individual veterinarian to do the best he can. He has to do it on his own. The poorer vet will like the subsidy because it will allow him to stay in business, whereas if he were in the marketplace, he would go out of business and we would be rid of an incompetent.

  12. I’m not sure formalized subsidized veterinary care should be encouraged to expand. I know of many veterinarians who donate or partially donate services on a case by case basis, thus enhancing the image of caring individuals, without downgrading the value of veterinary services. At the same time, I see lots of expensive cars outside the Humane Society or municipal Spay-Neuter clinics. And it’s hard for me to see where governmental programs aren’t a burden to general society, despite claims of doing good.

    • The Humane Society and the vast majority of spay- neuter clinics are not ” governmental organizations “. This is not an ideological issue. There are many options available for animals in need of care. Who are we to say that some forms of care should be blocked because they will negatively impact our bottom line. I don’t think that is a concern if you are capable of managing a successful practice and it sure is not a very caring line of thinking.
      I own a small animal Veterinary Clinic and have partnered and am proud of the great things that some of the not for profit rescue organizations have accomplished in my city. They serve a niche that traditional practice can not. The baseline concern should be- what is in the best interest of our animal population?

    • I think that with national/corporate practices & concern they could unduly influence AVMA Delegates, we have to first take a step back and determine if DVM within these organizations are even members of their state VMA & AVMA. Do these national/corporate practices have the resources & relationships to influence Congress & the Senate is a bigger concern, IMHO. Thanks for your perspective!:-)

    • I think that with national/corporate practices & concern they could unduly influence AVMA Delegates, we have to first take a step back and determine if DVM within these organizations are even members of their state VMA & AVMA. Do these national/corporate practices have the resources & relationships to influence Congress & the Senate is a bigger concern, In my opinion Thanks for your perspective!:-)

  13. The Federal Code is very clear and concise on the matter:

    [Code of Federal Regulations]
    [Title 21, Volume 6]
    [Revised as of April 1, 2017]
    [CITE: 21CFR530.3]

    TITLE 21–FOOD AND DRUGS
    CHAPTER I–FOOD AND DRUG ADMINISTRATION
    DEPARTMENT OF HEALTH AND HUMAN SERVICES
    SUBCHAPTER E–ANIMAL DRUGS, FEEDS, AND RELATED PRODUCTS
    PART 530 — EXTRALABEL DRUG USE IN ANIMALS

    Subpart A–General Provisions

    Sec. 530.3 Definitions.
    (a) Extralabel use means actual use or intended use of a drug in an animal in a manner that is not in accordance with the approved labeling. This includes, but is not limited to, use in species not listed in the labeling, use for indications (disease or other conditions) not listed in the labeling, use at dosage levels, frequencies, or routes of administration other than those stated in the labeling, and deviation from the labeled withdrawal time based on these different uses.

    (b) FDA means the U.S. Food and Drug Administration.

    (c) The phrase a reasonable probability that a drug’s use may present a risk to the public health means that FDA has reason to believe that use of a drug may be likely to cause a potential adverse event.

    (d) The phrase use of a drug may present a risk to the public health means that FDA has information that indicates that use of a drug may cause an adverse event.

    (e) The phrase use of a drug presents a risk to the public health means that FDA has evidence that demonstrates that the use of a drug has caused or likely will cause an adverse event.

    (f) A residue means any compound present in edible tissues that results from the use of a drug, and includes the drug, its metabolites, and any other substance formed in or on food because of the drug’s use.

    (g) A safe level is a conservative estimate of a drug residue level in edible animal tissue derived from food safety data or other scientific information. Concentrations of residues in tissue below the safe level will not raise human food safety concerns. A safe level is not a safe concentration or a tolerance and does not indicate that an approval exists for the drug in that species or category of animal from which the food is derived.

    (h) Veterinarian means a person licensed by a State or Territory to practice veterinary medicine.

    (i) A valid veterinarian-client-patient relationship is one in which:

    (1) A veterinarian has assumed the responsibility for making medical judgments regarding the health of (an) animal(s) and the need for medical treatment, and the client (the owner of the animal or animals or other caretaker) has agreed to follow the instructions of the veterinarian;

    (2) There is sufficient knowledge of the animal(s) by the veterinarian to initiate at least a general or preliminary diagnosis of the medical condition of the animal(s); and

    (3) The practicing veterinarian is readily available for followup in case of adverse reactions or failure of the regimen of therapy. Such a relationship can exist only when the veterinarian has recently seen and is personally acquainted with the keeping and care of the animal(s) by virtue of examination of the animal(s), and/or by medically appropriate and timely visits to the premises where the animal(s) are kept.

    • The Federal code is not at all clear to me in regard to who is responsible for establishing the VCPR. And it is also not clear what elements make that relationship valid. Is it the Client that should seek out the veterinarian and request that she/he be the prescribing veterinarian with sole authority? Or is it the veterinarian’s responsibility to define and communicate the nature of that relationship? Is that relationship valid with out a written, signed contract between the two parties? What is the frequency and scope of visits that constitute “sufficient knowledge”?

      I realize that the past history of veterinary medicine has put the veterinarian in the role of pharmacist, but from a regulatory point of view I think this role gives us a liability that should fall on the producer not us. On the vast majority of farms the producers treats their own animals, and they are the sole recipients of the proceeds from the sale of their products. I think they should have the sole liability for residues in any of the products they sell. ( I also think that there is a great ethical conflict of interest in the veterinarian benefiting from the sale of drugs, but that is a discussion for another day.) The FDA seems to me to be using our role on farms to do the education and regulation needed to help prevent residues in food products. We share in the liability when, ultimately, we are not in control of what animal gets treated with what drug at what dose and route of administration. Nor are we in control of the recording of those actions.

  14. I do not believe in subsidizing veterinary medicine. There are way too many things subsidized now. Some type of voluntary charity would be OK. . As for one size fits all doctor client patient relationship, it will probably suit some clients, but I do not think it will replace the personal touch of the private practice. From what I have seen in my area, many people switch veterinarians when a corporate practice takes over. I usually make my diagnostic and therapeutic decisions on a case by case basis on the spot taking in consideration the patient, the client, the home situation, etc.

  15. For the betterment of all the animals. non-profits that supply services are important. I have found after 50 years as a Veterinarian, that people with limited means need places to go for help with their animals. Of course there are people who take advantage of this situation, and this is unfortunate, but I have found them to be few and many times they can be “shamed” into using normal services. We can do more good in raising our professional image by servicing the needy, rather than being known as “money grabbers”. And unfortunately there are those among us that promote that image.

  16. Veterinary Client Patient relationship is NOT one-size fits all. How could it be when we see a vast array of species? A large animal vet with a herd of beef cattle on a cow-calf ranch is certainly not going to have the same relationship with his clients/patients as a small animal veterinarian. And zoo and wildlife vets are vastly different in their approach compared to anyone else. So asking for a one-size fits all is like asking for bandage material to be one size fits all. Not going to happen. Also we SO do not need to nationalize veterinary medicine. Its called an Art and Practice because what works for you may not work for me. I can’t get mirtazapine to last 72 hours in cats, but hey cyproheptadine still works well. I use acupuncture in addition to western modalities do you? If we nationalize medicine will we be able to do things the way that works for us and our area/financial resources of clients? Probably not. So Congress stay out of my exam room!!!!

  17. Delivery of care by non-profits:
    Such programs represent an important means of protecting the health and welfare of animals, promoting public health, and preserving the human-animal bond. In most cases such care supplements other forms of veterinary care available in a given community and, as indicated by their success, are addressing an unmet need. Such clinics enhance the public perception of veterinary medicine by ensuring access to care for all animals, regardless of limitations of their caregiver.

    VCPR:
    Species, practice type, and location should indeed impact how the VCPR is defined. The AVMA Model Practice Act section 6.17 is a good example of how a VCPR can be defined so as not to hinder the delivery of needed care. In this case, the population excepted is shelter animals and such exceptions are supported by professional standards (http://www.sheltervet.org/assets/docs/position-statements/veterinarysupervisioninanimalshelters.pdf).

    Restrictions on the VCPR that require a physical exam or exclude formation of a VCPR via electronic or telephonic means restrict access to care for the most vulnerable patients and/or may require an office visit when it is not in the best interest of the patient’s well-being. The establishment of a VCPR should be up to the veterinarian and client when, in the veterinarian’s professional judgment, enough information has been gathered to render an appropriate medical decision. Such information can and should include a variety of formats including newer technological modalities.

    • A valid VCPR protects the public – whether it be a on-on-one with our client in the hospital, or the end consumer of a food animal product. I understand it is not practical to examine an entire herd or flock, however, the VCPR does allow for herd health contingencies. As for shelter and rescue situations, there should be an interactive relationship with good commuication between the DVM and the responsible care provider. Who are we relying upon to provide accurate examination and patient information if the DVM does not perform an examination? Minimizing the role of the DVM would be disastrous – could a care giver buy a medical textbook and diagnose and treat without the DVM? It cheapens the DVM degree, minimizes responsible medical judgement and allows irresponsible medical therapies – overuse of antibiotics being just one case. We may delegate care giving, but we are still ultimately responsible. And, we should be responsible; we should hold higher standards.