Law creates nurse practitioner type of job as state considers more veterinary bills
A new law in Arkansas opens the door to radically expanding the scope of practice for veterinary technicians in that state, potentially accomplishing in short order what the veterinary profession has talked about doing for decades: better tapping the skills of these essential members of the veterinary team.
Allowing technicians to do more of what they are already trained to do will counter low morale and turnover, it's widely believed, while helping to ease the burden on overstretched veterinarians. On this topic, there have been colloquies, surveys, initiatives and even a new master's degree program, but no structural change — until now.
The Arkansas bill, HB1182, signed by Gov. Sarah Huckabee Sanders late last month, was promoted as a way to address a shortage of veterinarians in the state. It creates a state certification for a veterinary technician specialist role with the authority to diagnose, develop treatment plans and establish, on a preliminary basis, a veterinarian-client-patient relationship (VCPR) — in collaboration with a veterinarian.
The veterinary technician specialist established in the new law builds on a national veterinary technician specialist (VTS) certification.
The development was greeted with cheers from leaders of veterinary technician organizations.
"I think that this will help us make leaps and bounds toward professional growth for technicians in Arkansas," said Kaitlin Frakes, president of the Arkansas Veterinary Technicians Association. The National Association of Veterinary Technicians of America endorsed the bill.
Key veterinarian associations opposed the measure. The Arkansas Veterinary Medical Association and the American Veterinary Medical Association lobbied for changes to the original bill — successfully on some provisions but not all.
"We do not believe this new law serves the best interests of patients, clients, or the public," the AVMA says in a post on its website.
HB1182 is one of several controversial bills focusing on veterinary medicine in Arkansas this session. A measure that would have required veterinarians to treat all emergencies regardless of whether clients could pay was introduced and withdrawn by the author in under a week. Still pending is a bill that would allow a veterinarian to establish the VCPR through telemedicine rather than requiring an exam in person; and another that would dissolve the Veterinary Medical Examining Board and move its responsibilities to the state Livestock and Poultry Commission.
Yet another veterinary-centric bill was added to the docket last Friday. HB1673 would qualify individuals with a bachelor's degree in animal science and a pre-veterinary emphasis to become certified veterinary technicians. In a case of whiplash, some of the technicians who celebrated the addition of a veterinary technician specialist role to the practice act are gearing up to fight this latest measure.
"This would put our patients at great risk, as the curriculum for that degree is very different than that of an AVMA-accredited veterinary technology program," Frakes said, referring to the AVMA's Committee on Veterinary Technician Education and Activities. For example, she said, animal science degree programs often don't cover many of the skills taught in technician training programs, such as pharmacology, radiology, phlebotomy and anesthesia.
What is a veterinary technician specialist?
Veterinary technician specialists in the new law must have two levels of credentialing. First, they must be certified veterinary technicians, or CVTs, which means completing an AVMA-accredited education program, passing a national exam and completing 12 hours of continuing education each year.
Second, they must be certified as a national veterinary technician specialist (VTS) and complete an additional 8 hours of CE each year.
A technician with a VTS is analogous to a veterinarian board-certified in a specialty. Requirements to become a VTS vary by the specialty, but all include three to five years of work experience after being credentialed, case logs and reports showing work in the specialty area, recommendation letters and passing an exam. The specialty organizations, known as academies, are overseen by NAVTA. There are about 1,500 veterinary technician specialists worldwide in 16 specialties, including emergency and critical care, anesthesia and analgesia, behavior, rehabilitation and nutrition.
Under the new law, known as Act 161, a veterinarian and veterinary technician specialist may enter into a written "collaborative practice agreement" for the joint management of animal patients. Under the supervision of the collaborating veterinarian, the technician specialist may establish care for new animal patients by forming a "preliminary VCPR," order diagnostics, provide a diagnosis or prognosis, and develop a treatment plan with a collaborating veterinarian.
The sponsor of the law, Rep. DeAnn Vaught, has compared the new role to that of a nurse practitioner in human medicine. Collaborative practice agreements are a feature of nurse practitioner regulations in many states.
"To me, it's no different than nurse practitioners," Vaught reportedly told the House in early February. "We did not have enough doctors, so what we did was let nurse practitioners do more and more to help with the shortage of doctors. And we got that same shortage with veterinarians." Vaught did not respond to calls and emails from the VIN News Service.
The effort to create something like a nurse practitioner or physician's assistant in veterinary medicine dates back to at least the 1990s. More recently, Lincoln Memorial University College of Veterinary Medicine in Tennessee started offering a Master of Veterinary Clinical Care. The degree is designed to serve as the educational basis for a to-be-defined midlevel professional.
Critics of LMU's degree said it would take states changing practice acts — something generally deemed a steep challenge — for graduates to translate their master's into a job with a wider scope of practice.
Arkansas added the midlevel position to its practice act de facto, using the different educational pathway of the VTS.
This is as it should be, in the view of Charlotte Waack, director of the Veterinary Support Personnel Network, a part of the Veterinary Information Network, which is the parent of VIN News.
"This is what I've always said about the midlevel practitioner — we already have them," Waack told VIN News. "I consider VTS-credentialed technicians to have the skills and knowledge of a midlevel practitioner, but they are not being utilized to their fullest. We need to write them in our practice acts, and Arkansas is doing everything I dreamed of."
Modifications made; ambiguities remain
Arkansas lawmakers shake up veterinary medicine
Dr. Everett Rogers, president of the Arkansas VMA, observed that the law opens the door to big changes for technicians. "This has really, really expanded their scope of practice tremendously," he said. "It's almost equal to a veterinarian."
As originally written, the bill would have extended the scope of practice even more.
The Arkansas VMA lobbied to remove some of the more ambitious provisions. For example, when the bill was first introduced, it would have given technician specialists the authority to prescribe.
"This is in conflict with all the federal regulations and rules regarding prescription writing, whether we go from the FDA, the DEA, whichever," Rogers said, referring to the U.S. Food and Drug Administration and U.S. Drug Enforcement Agency. "No one authorizes anybody other than a licensed veterinarian to write a prescription."
The prescription authority was pulled from the bill, as was a provision that would have allowed technician specialists to be paid directly by clients. Rogers said allowing for an independent relationship between clients and technicians raised questions about whether the collaborating veterinarian's malpractice insurance would cover acts performed under those circumstances. In the bill version that passed, technician specialists are salaried employees of collaborating veterinarians.
(In this way, veterinary technician specialists are not like nurse practitioners, who can be paid directly by patients.)
Rogers highlighted two areas of concern that made it into the law. Technician specialists are allowed to "perform minor dental and surgical procedures," excluding abdominal, thoracic or orthopedic surgery and neurosurgery.
The provision makes for "a lot of gray areas," Rogers said. Others who talked to VIN News also pointed to the surgery provision as being too vague. VSPN's Waack suggested that a list of allowed procedures would have been helpful.
Another problematic aspect of the law, Rogers said, authorizes technician specialists to establish a preliminary VCPR, which he said seems to conflict with the federal definition of VCPR as being the exclusive province of veterinarians.
Act 161 appears to try to get around that restriction by requiring that the collaborating veterinarian "complete" the VCPR by seeing the animal within 15 days of the first appointment with the veterinary technician specialist.
But, Rogers said, "a lot can happen from day one to day 15."
Dr. Lindy O'Neal, who co-owns a small animal practice in Rogers, Arkansas, echoed that concern. Overall, O'Neal said, she sees lots to commend in the new bill. She said she runs a technician-driven practice and believes several of her technicians would be good candidates for the new role.
However, she feels the law has problems. In particular, she expressed reservations about the 15-day VCPR window, which she called a "weird loophole that doesn't make any sense in small animal medicine."
She imagines a case of a dog erroneously identified during a first visit by a technician specialist as having kennel cough. The dog goes home, only to die of undiagnosed pneumonia or cancer. In such a scenario, under the law, O'Neal said, "I'm responsible, even though I never saw the patient, nor got to fulfill the VCPR requirement."
There is also the chance a pet owner won't return for the appointment with the veterinarian, she said.
O'Neal noted that the situation is different with large animal patients. In such instances, the veterinarian usually travels to the animal's location, which ensures that they will establish a VCPR.
She worries that not enough time was spent developing the legislation to work out the wrinkles. "The human nurse practitioner role has been tweaked over the years," she said. "This decision for a midlevel veterinary professional was made in haste."
Rogers of the Arkansas VMA said he hopes that veterinarians' criticisms of the early versions of the bill, as well as some provisions of the law, are not read as denigrating technicians.
"We hold technicians in extremely high regard," he said, "and we couldn't do the work we do without them."
No veterinary technician specialists in the state yet
While Act 161 is positioned as a fix for the shortage of veterinarians in Arkansas, that fix will take some time to take effect. Currently, there are no veterinary technician specialists in the state who could qualify for the role. However, Frakes, president of the state veterinary technicians group, said she knows of two technicians who are working toward specialist credentials.
Acknowledging that the bill garnered negative attention from some veterinarians, she said, she's hopeful it will prove its value in the long run.
"I just wish that more people could see the positive impact that I feel it can have," she said. "In Arkansas, we are in a very, very underserved area, as far as veterinary care is concerned … [and] if everything goes the way that we want it to, we'll be able to see more patients with quality veterinary care."
Parallel midlevel track abides
Meanwhile, LMU enrolled 27 students in its first Master of Veterinary Clinical Care class last fall, according to Dr. Stacy Anderson, dean of the veterinary school. She said LMU anticipates that four of them will graduate this fall. The 30-credit online program can be completed in three semesters, but students are allowed to go at their own pace for up to six years. Tuition is currently $19,500.
Another master's degree program in the works is under study at the Colorado State University College of Veterinary and Biomedical Sciences. Dr. Wayne Jensen, head of the Department of Clinical Sciences there, said a proposed Master of Veterinary Critical Care will undergo review starting in April. The review process could take a year or longer, Jensen said.
Clarification: The description of the new master’s at CSU has been revised to reflect that it is not exclusively aimed at veterinary technicians.
Update: Upon its adjournment April 7, the Arkansas Legislature passed only one more veterinary-medicine-related bill — SB 403, which dissolved the veterinary board, transferring its duties and authority to the Arkansas Livestock and Poultry Commission. The final version of the legislation directs the commission to create a committee of four veterinarians — two from the commission and two from small animal practice — to make recommendations on rulemaking, disciplinary issues and ethic complaints, effectively having the same functions as the veterinary board. Through the committee, "[W]e have a voice at the table," said Rogers, president of the Arkansas VMA.