This question is poised to me by pet parents on an almost daily basis. It is also one that puts me immediately on guard. Why? As a board-certified veterinary internal medicine specialist, my primary obligation is to advocate for your pet’s healthcare. But my patients come to me through referrals – referrals from primary care doctors. Therefore professional courtesy dictates that I must always be exquisitely careful not to undermine my colleagues because if a pet parent perceives I believe their family veterinarian made a mistake or should have done something differently, that parent will inevitably go back to his/her referring doctor and tell him/her that I said s/he made a mistake or should have done something differently. This understandably can create animosity on the part of my primary care colleague and ultimately a loss of patient referrals from that doctor. Thus I become limited in my ability to do my job – advocate for patients – because my referral population disappears.

Does this sound political to you? It should. For better or worse, this is the way it is. With that being said, even if I could answer the question posed in the title of this post, the answer truly is not an easy one by which to come. Thus the goal of this post is to make pet owners aware of some of the reasons why a board-certified veterinary internal medicine specialist tries to avoid the title question like the plague!

I wasn’t there…

This is a very important point. I don’t have the ability to see the past. I don’t know exactly what you told your family veterinarian at your initial consultation with him/her. I don’t know exactly what your pet looked like when you first presented him/her to the primary care doctor. I don’t know if you followed all of your veterinarian’s instructions to the tee. I simply don’t and can’t truly know what triggered the choices made by your family veterinarian. Thus it would be utterly inconsiderate, unprofessional and potentially dangerous for me to try to step into the mind of a primary care doctor.

We’re trained differently…

I had to go through some very extensive training to become a board-certified veterinary internal medicine specialist. After four years of veterinary school, I chose to pursue additional clinical education that included a 1-year rigorous internship and two residencies (internal medicine and emergency/critical care); a residency is typically 3-5 years in length. One should note internship and residency training is not required for veterinarians as it is for medical doctors (MDs). The culmination of every veterinary residency program is successful passing of an intense, multi-day, board-certifying examination (and some specialties have more than 1 test).

I describe this supplementary education because it is this very training that shaped how I approach a patient’s medical problems. Board-certified veterinary internal medicine specialists think differently than primary care doctors. Please do not interpret this statement to mean we are smarter or think better than our family veterinary colleagues.

We just think differently because of our advanced training.

We ask different questions and we even ask questions differently. We see trends where they are not obvious. We look at test results with a discerning eye; a normal result on paper may actually be significant to us. A non-medical person knows what a surgeon does, but the same unfortunately can’t be said for the public’s awareness of an internal medicine specialist’s skills. I don’t have the luxury of showing off a lot of fancy equipment – my fancy equipment is my brain, a tool that has been molded to approach complicated medical problems in a very unique way.

A specialist’s patient population is different…

In some ways, a board-certified veterinary internal medicine specialist is a primary care doctor’s doctor. I don’t get to see healthy patients. I honestly can’t remember the last time I examined a healthy puppy or kitten. Since I see various diseases more often than my primary care colleagues, I also think about them more frequently.

A classic example of this is that of Addison’s disease, a syndrome in dogs (and rarely cats) characterized by inadequate function of the adrenal glands. In the general dog population, this malady infrequently occurs naturally (0.6-2.8 cases per 1000 dogs); but in my clinical practice, I may diagnose it two or three times a month! So I see Addison’s disease more frequently than my colleagues who practice primary care, and thus I think about it more often too. That means I perform the blood test to screen for the disease more habitually, and because I look for Addison’s disease more regularly, I diagnose it more commonly.

And sometimes they’re wrong…

This section is, perhaps, the most difficult one to write because one of my primary goals in my effort to advocate for my patients is not to undermine those who refer patients to me. Nevertheless we all make mistakes. I know I have, and so too do primary care doctors who refer patients to me for evaluation. When these mistakes are made, I’m inevitably caught between a rock and a hard place. Do I keep quiet about the mistake because I know I’ll be able to move forward in the patient’s best interest? Or do I tell parents that another doctor made a mistake and then try to focus their attention on the next steps for their pet? And if I do tell them about a mistake, how do I do so without throwing my colleague under the bus. This is often much easier said than done. Remembering my goal is patient advocacy to ensure the best possible healthcare, I always try to remain positive by steering the diagnostic investigation and therapeutic plan forward. It is in a patient’s best interest to guide families to focus on getting their pet becoming healthier.

The take-away message…

A primary care doctor and a board-certified veterinary internal medicine specialist are certainly not the same. This statement is by no way meant to besmirched the extraordinary work of my colleagues in primary care. I wholeheartedly believe in the “triad of care” – pet family, primary care doctor and veterinary specialist – all partnering together in a concerted effort to maximize the best possible outcome for a pet. When you meet with an internal medicine specialist, I encourage pets parents to avoid the “Why couldn’t my vet figure it out?” question because it is not productive; we want to focus our efforts solely on properly diagnosing and treating your pet’s medical condition to ensure the highest possible quality of life for as long as possible.

To find a board-certified veterinary internal medicine specialist, please visit the American College of Veterinary Internal Medicine.

Wishing you wet-nosed kisses,

cgb