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How to Define Your Success as a Clinician

Barry Kipperman

Abstract

This chapter considers finding a suitable criterion by which to assess success in clinical veterinary practice and why this is important. It discusses the limitations of satisfying varied practitioner interests including those of referring veterinarians, performing advanced treatments or procedures, financial compensation, conforming to employer expectations, pleasing animal owners, and achieving desired patient outcomes as benchmarks for success. Case studies are used to illustrate these examples. The Principle of Patient Advocacy is defined and introduced as the ideal means by which to determine clinician success.

Keywords: success, moral stress, referring veterinarian, compensation, employer, advanced care, clients, owners, patient advocacy

As this book is devoted to veterinary decision-making, perhaps one of the most meaningful decisions is how to define one's success as a clinician. During my career, numerous interns and students have asked me, "How do you know whether you are a good veterinarian or had a successful day?" I had no answer to this profound question when it was first posed, but significant introspection since then has allowed me to gain clarity, which I hope to provide in this chapter.

Why is the answer to this question so vital? Because whatever criterion one uses to measure success will inevitably guide one's practice philosophy and behaviors that may endure over the course of an over 30-year career in the profession. Another reason grappling with this question is so important relates to the mental health of veterinarians. There has been increasing research interest in examining the occurrence of stress within the veterinary profession. Many factors have been cited to cause stress, including ethical dilemmas, client financial limitations affecting patient care, work overload, client complaints, and dealing with death and errors [1].

Two recent investigations discovered that 50% [2] and 31% [3] of veterinarians had high burnout scores. A study of small animal veterinarians found that 49% reported a moderate to substantial level of burnout [4]. In another report, when North American veterinarians were asked "How often have you felt distressed or anxious about your work?", 52% responded "often" or "always" [5]. It's apparent that work-related stress is a significant challenge for the veterinary profession. The effects of work-related stress on mental health are well documented and include emotional exhaustion, anxiety, and depression [6, 7]. Numerous studies have documented higher rates of suicidal ideation and suicide in the veterinary profession compared with those in the general population and other healthcare professionals [8-11].

If one applies a standard of success that becomes unfulfilling, too difficult, or impossible to attain, it's likely that moral (dis)stress may be experienced. Moral distress has been defined as "The experience of psychological distress that results from engaging in, or failing to prevent, decisions or behaviors that transgress . personally held moral or ethical beliefs" [12]. Moral stress is therefore recognized as a consequence of experienced conflicts involving work-related obligations or expectations that do not coincide with one's values [13, 14]. Studies in veterinary medicine have suggested or documented that moral distress is inversely associated with wellbeing and correlates with career dissatisfaction and attrition [15, 16].

To consider the question of how to assess your success, let's systematically examine the numerous interests veterinary clinicians are expected to serve and the viability and limitations of satisfying each of these as a benchmark to evaluate clinical success.

Referring Veterinarian

To meet the demand that medical care for animals rival that of humans, the number of referral and emergency veterinary practices in the United States has increased dramatically in the last three decades [17]. Of the estimated 119?000 US veterinarians [18], 11% are board-certified specialists [19]. These veterinarians have the same diverse obligations as those of the referring veterinarian (RDVM), but in addition must satisfy the perceived or real demands of the RDVM.

Just as general practitioners (GPs) are economically dependent on the animal owner for their livelihood, the veterinary specialist is dependent on present and future referrals from their colleagues. As most pet owners are not aware of the existence of specialists [20], the GP is considered the gatekeeper to the referral process. While GPs are careful not to offend pet owners, specialists feel the same way toward RDVMs due to concern over losing referrals and their associated income.

As a result of these forces, the veterinary specialist may feel conflicted in satisfying their varied duties (Case Studies 1.1 and 1.2).

Case Study 1.1 A Dog with Chronic Vomiting Referred for Endoscopy

You are an internist in a referral practice. Bella, a nine-month-old dog, is referred for endoscopy for evaluation of chronic vomiting. Novel diet trials have not been performed and appetite is normal. Lab work and radiographs are within normal limits. Physical examination reveals Bella to be in good body condition with no abnormalities. Based on Bella's young age and the evaluation, you advise a novel diet trial for food allergy/intolerance, with endoscopy and biopsies to follow if vomiting does not improve within a few weeks.

The client seems confused and explains that endoscopy was advised by her veterinarian. You inform the client that approximately 50% of cases like Bella's will respond to diet change, supporting the recommendation to delay the cost and anesthetic risk of endoscopy and the need for medications that may have undesirable side effects. The RDVM calls you later in the day to express his displeasure with the agreed course of action, stating, "You showed me up to the client because I wanted an endoscopy. Now I'll refer her to someone else who will do the endoscopy."

In this case, there is conflict between what the specialist perceives to be in the best interest of the patient and the expressed desire of the GP. Ideally, this problem can be sufficiently resolved via a professional conversation. If not, should the specialist comply with the request for the endoscopy? This procedure is benign, commonly performed, and will enhance the income of the specialist, but may be unnecessary for the patient.

Case Study 1.2 A Dog with Abdominal Distension

Sydney, an 11-year-old male German shepherd, is seen by a local GP on Wednesday for lethargy and poor appetite of 1-2?days' duration. The medical record confirms abdominal distention. Sydney is sent home while a mobile ultrasound is scheduled. On Friday, ultrasound reveals a splenic mass. Sydney is sent home for the weekend and arrives at your referral practice Monday morning in a moribund, life-threatening condition, with a packed cell volume (PCV) of 17%. Sydney undergoes emergency splenectomy for abdominal bleeding and dies postoperatively from oliguria and coagulopathy. Should you inform the client or the GP of your concern that surgery should have been advised before 5?days had passed after initial presentation? Should you report this colleague to the state board?

While in many cases the interests of the GP, specialist, client, and patient are aligned, conflicts can occur. Unfortunately, attempts by the specialist to constructively discuss with the RDVM what could have been done better sometimes result in a punitive loss of future referrals. If satisfying the RDVM is viewed as a measure of success, then the specialist may either modify their standards of practice to conform with GP expectations, or may not attempt to provide constructive feedback to GPs to improve their standards of practice. Both choices are detrimental to promoting animal welfare. Conversely, a GP should also feel they can discuss concerns about shared patient care with the specialist. While striving to satisfy RDVMs may seem appropriate as an indicator of success, these examples suggest that in some cases doing so can be self-serving and disregard obligations to the client, the patient, and the profession.

Veterinarian

Veterinary clinicians have an interest in career satisfaction. Professional self-esteem may be linked to learning and performing novel or advanced procedures or treatments [21]. The increased demand of animal owners for advanced care and the rise in availability of emerging technologies and advanced imaging create a recipe for futile or non-beneficial interventions. As noted by Durnberger and Grimm [22]: "Undoubtedly, veterinarians have a positive duty to help animals - but at what point do they run the risk of violating the negative duty not to harm animals?" In considering this issue of when well-intended interventions cause unwarranted harm, studies show that veterinarians are sometimes requested to provide treatment that they consider futile [5, 23].

Emotionally driven factors are often associated with decisions to pursue advanced care (Case Study 1.3). Taylor [24] has noted that...