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California veterinarians target unlicensed care

Conflict between profession, lay practitioners intensifies


December 14, 2010
By: D.A. Griffith
For The VIN News Service


The California Veterinary Medical Association (CVMA) is preparing a crusade against unlicensed veterinary medical activities such as anesthesia-free teeth cleaning for dogs and cats, ultrasound pregnancy testing of livestock and physical rehabilitation for animals of all sorts.

The planned campaign aims to warn animal owners and producers of the dangers of unlicensed veterinary care, as well as clarify and toughen regulations and sanctions against those who practice veterinary medicine without a license.

“This has been going on for many, many years, and it is getting worse,” said Valerie Fenstermaker, executive director of the CVMA. “Our members see animals coming into their practice who are injured and harmed by unlicensed persons, and yet there is no effective recourse for the owners. At this point, our association is looking at options for stricter laws to better protect the public and animals.”

CVMA officials say they are receiving an increasing number of complaints about animal care providers who aren’t licensed veterinarians who are diagnosing and treating patients — activities that in California fall strictly under the purview of veterinarians.

The California Veterinary Medical Board (CVMB), which licenses and disciplines veterinarians, acknowledges the problem but notes that the board can do little to stop unlicensed activity. While the CVMB is charged with protecting the public, non-veterinarians who dabble in veterinary medicine do not have licenses at risk with state regulators.

“Our role is defined in law, and our authority is not as great over non-licensed practitioners as it is over licensed veterinarians,” said Susan Geranen, the board’s executive officer. “To some extent, our hands are tied.”

Lay-practice advocates say they are answering the public's demand for services that veterinarians often do not offer. They maintain that veterinarians usually are unwilling to hire or otherwise supervise non-licensed practitioners in a legal capacity, leaving them little option but to operate with dubious legal status.

Although state statutes differ, as do consequences for unlicensed activities, both sides have engaged in turf battles for years in nearly every part of the country. Both sides agree that conflicts have intensified as consumer demand for convenient, less expensive animal care has grown.

California veterinarians say the real price for unlicensed medical practice is paid by the dogs, cats, horses and other animals that may be misdiagnosed or harmed and by owners who have no recourse because unlicensed practitioners typically aren't held accountable.

In California, the veterinary medical board can issue cease-and-desist letters to known violators and issue fines up to $1,500 for unauthorized practice. That’s where it ends unless the state attorney general's office, serving as the CVMB's legal counsel, prosecutes the case — a rare occurrence in The Golden State. 
 
In the past six months, for example, the CVMB issued five citations involving the practice of unlicensed veterinary medicine, but could not convince a district attorney to prosecute a single case.

Geranen recalled a case from 2005 in which a groomer was prosecuted for allegedly breaking a dog’s jaw while cleaning its teeth, but an administrative law judge dismissed the case due to a lack of witnesses.
 
“I have gone out personally (to) the attorney general’s office and talked to local district attorneys and asked, ‘How can we put the case together so that you’ll take it?’ They say with limited resources, they have to make humans their priority,” Geranen said.

Animal owners easily can find these unlicensed services through breeders, boarding and grooming businesses or professional provider organizations such as the International Association of Animal Massage and Bodywork. The Internet is replete with websites for all kinds of unlicensed animal care that offer some type of medical treatment.

The website for Medicine Hat Animal Chiropractic in San Diego County, for example, advertises the services of Dawn E. Fletcher, who states that she ran a human chiropractic practice and now specializes “solely in the treatment of horses” and offers “a variety of equine physio-therapeutic modalities.” A message left for the business by the VIN News Service seeking information about Fletcher's practice went unanswered.

American Dog Physical Rehabilitation for Animals, also in San Diego, offers “therapeutic laser,” an approach the website says “is beneficial in the treatment of, but not limited to … arthritis, inflammation, muscular pain, nerve pain, wounds/incisions and scar tissue.” The owner of American Dog directed questions from the VIN News Service to the American Physical Therapy Association.

In Claremont, “Tammy The Teeth Cleaner” bills herself as a “pet dental hygienist,” offering a $105 anesthesia-free teeth cleaning service that involves “hand scaling and polishing the teeth while checking for loose teeth, gum disease and any abnormalities.” Business owner Tammy Cisneros declined to be interviewed by the VIN News Service.

Dr. Ronald Kelpe, a veterinarian in Rancho Santa Margarita, has particular concerns about anethesia-free dental care. Under California law, hygienists are allowed to brush and floss teeth but cannot use any other instruments such as scaling devices in animals’ mouths.

“In the last month, I have seen two dogs who came in whose teeth were spit polished, but mobile and painful," he said. "We took radiographs of the mouth and teeth, and in both cases, more than 12 teeth had to be removed.”

The problem, said Kelpe, is that dental conditions aren't being detected or managed properly by those who aren't trained to practice veterinary medicine.

“People feel that they got a good deal because the dog’s mouth looks clean and the breath smells better,” Kelpe said. “The (cleaner) got the obvious calculus on the crown removed, but it’s what’s under the gum line where the problem starts and finishes.

“Potentially, we have allowed this bacterial invasion locally into the root socket, but also widespread in the bloodstream. It has gone unnoticed and untreated.”

Maia Bazjanac describes herself as one of the rare animal hygienists who practices with veterinary supervision. She works with a clinic in El Cerrito. Bazjanac agrees that there are poorly trained animal teeth cleaners who can miss important problems, and there is no agency overseeing their work or meting out discipline when warranted.

But she said much of the problem is that veterinarians don’t want to offer the service themselves or contract with a hygienist to do the work for them for fear of ostracism by peers.

“Most of the hygienists out there that I know would be happy to work under vet supervision, but it’s basically impossible to get vets to work with them,” she said. “There has been an ongoing smear campaign against the procedure itself, and many vets are completely ignorant of how it is done and how good its results are.”

Fenstermaker counters that veterinarians are ultimately responsible for the welfare of their patients, so they must be careful to choose staff wisely.

“It’s likely that a veterinarian would be reluctant to hire a dental hygienist due to a lack of a formal education on the medical care of animals,” she said. “If the dental hygienist really wants to work for a veterinarian, he or she may want to consider becoming a registered veterinary technician.”

Veterinarians also oppose unsupervised work of physical therapists and chiropractors. Fenstermaker says that just because a person has a license to practice on humans doesn’t mean they can also work on animals without the direct supervision of a veterinarian.

Just as veterinarians can't treat people, she said, “those who are licensed to practice on humans cannot cross the line into animal care.”

Justin Elliott, director of state government affairs for the American Physical Therapy Association (APTA), is hoping to clarify the role that physical therapists can play in animal health in California and around the country.
 
He said about 400 licensed APTA members specialize in animals, but more than 40 states specifically limit the practice of physical therapy to humans, which means the therapists are restricted from working under their physical therapist license and must work as unlicensed technicians under direct supervision of a veterinarian.
 
Elliott emphasized that many physical therapists agree with veterinarians that unlicensed animal rehabilitation activities should be prohibited. The California Physical Therapy Association (CPTA) is working with the CVMB to come up with a model in which licensed physical therapists can work collaboratively with veterinarians. While the CPTA is open to referral arrangements or some other collaborative model, the association opposes direct supervision.

By definition, direct supervision requires a veterinarian to be physically present when a non-veterinarian treats an animal.
 
“Of all the issues we have, direct supervision causes the most heartburn,” Elliott said. “Physical therapists are licensed professionals. They are experts in the field of animal rehabilitation. Having a veterinarian in the room watching them all the time is unnecessary.”
 
That level of oversight also would be impractical, he argued, because a veterinarian would probably be unable or unwilling to accompany a physical therapist on a visit to a farm to work with horses or cattle, or to home visits to provide services for pets.

Another area of controversy is the use of ultrasound to test livestock for pregnancy, a field that some say attracts unlicensed technicians by necessity, but potentially at the risk of diminishing the quality of care.

Dr. Joan Rowe is a professor at the University of California, Davis, School of Veterinary Medicine with extensive experience in pregnancy testing of sheep and goats. Although unlicensed ultrasound does not harm animals, she said, a practitioner without the requisite training risks missing important diagnoses.

“I am not just detecting pregnancy but noting an abnormal pregnancy, a pending abortion or detecting a mummified fetus or pyometra,” she said.

In addition, Rowe examines the distributions of the stages of gestation among the flock and develops a diagnostic plan to assess problems.

She explains: “I am also on the lookout for mammary glands that are abscessed, noticing the body condition of the ewes, detecting abnormally thin animals that might need to be examined or removed from the flock, and watching for evidence of contagious foot rot.”

Dr. Nancy East was one of the first to develop ultrasound techniques used for large herds. During her years in practice in Northern California, she witnessed a gamut of ultrasound providers, “from the backyard goat lady who goes to the surplus and buys an inappropriate machine and teaches herself to do ultrasound, to the (unlicensed) guys who go to New Zealand to get trained and are really good,” East said.

Now retired from practice, East also raises sheep. She knows there is a critical shortage of veterinarians who specialize in pregnancy testing. For that reason, she advocates a less stringent approach to addressing lay practice in this area.

“We need to provide training and some sort of licensing procedure or graduate certificate for non-vets and veterinarians, too,” she said.

It is unclear whether professional veterinary groups will be willing to compromise to meet consumer and producer demands for services that might be difficult to obtain otherwise.

Fenstermaker said the CVMA must review any compromises proposed, and the state Legislature is charged with passing statutory changes. Amending regulations governing veterinary medicine in the state requires the CVMB to hold public hearings.
 
In the meantime, the CVMA has launched a membership survey to learn the extent of unlicensed veterinary activity and its reported consequences.

Fenstermaker and others critical of lay practice hope the survey results help stimulate the creation of tougher state regulations, laws and penalties designed to curb the role of unlicensed practice across-the-board.

“More needs to be done,” she said. “There needs to be stronger enforcement and stronger laws in place to protect animals.”

An earlier version of this article incorrectly stated that American Dog Physical Rehabilitation for Animals did not respond to a request for an interview. In fact, the owner referred the VIN News Service to the American Physical Therapy Association for comment.




VIN News Service commentaries are opinion pieces presenting insights, personal experiences and/or perspectives on topical issues by members of the veterinary community. To submit a commentary for consideration, email news@vin.com.



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