Veterinary internships lack uniform quality

Concerned about exploitation, AAHA offers new accreditation option

February 24, 2015 (published)
By Christy Corp-Minamiji, DVM

From the beginning, the veterinary intern sensed something was amiss.

Under the heading “Is it me?” the new veterinarian laid out to colleagues in an anonymous message board post a multiplicity of things going wrong at the hospital:

“Rotations had been canceled and time spent on emergency appeared underestimated. Currently, I ... work about 80 hours a week, with usually two to three days off per month. … On emergency weekends, I will work at least 14 hours a day with no breaks (often I did not eat anything due to high caseload.) The stress, of course, is very high, as nothing I see is healthy!

“The work environment is negative. Early on, I told my advisor that I did not expect to be praised, but hearing only one negative comment about my performance after another was quite hard. As an intern, he said, I was obviously the lowest-ranked employee, and that many interns did not enjoy their internships.”

More experienced practitioners quickly offered solace. “You don’t have to put up with this situation,” said Dr. Duane Moore, who’s been in private clinical practice for more than 20 years and owns a practice in Colorado. “It is not normal or right.”
That conversation took place three years ago on the Veterinary Information Network, a membership organization and online community for the profession. Today, concerns persist in the profession about the potential exploitation of veterinary interns, fueled by the increased popularity of internships among new graduates and the fact that no one regulates the field.

While individual hospitals or groups of hospitals may hew to formal in-house standards, and the American Veterinary Medical Association has internship guidelines, no universal enforceable standards exist to ensure that interns reliably receive the extra training and support they’re hoping for.

The American Animal Hospital Association is one of several groups attempting to fill gaps in internship regulation. Last fall, its board adopted an internship-accreditation program that AAHA-accredited practices can add to their credentials. Nine practices now have accredited internship programs, AAHA spokeswoman Kate Spencer said.

AAHA has posted general information about the new accreditation option, but the standards themselves are available for viewing only by AAHA members, including its 3,500 accredited hospitals. Only AAHA-accredited hospitals are eligible to pursue internship accreditation, and only those hospitals with accredited internship programs are obligated to follow the standards. Nevertheless, AAHA past president Dr. Mark Russak sees the criteria as a step toward greater oversight and quality-control of veterinary internships overall.

“My goal is to take these internships where these kids are getting blindsided and (redirect prospective interns to programs) … where they know what they’re guaranteed,” said Russak, who helped develop the standards.

Veterinary internships are one-year programs that are supposed to provide brand-new doctors with mentoring and more clinical experience before they start their careers in earnest. The programs may be focused on general practice or involve a rotation through specialties to give in-depth experience to those aiming to become specialists. Internships are offered in university teaching hospitals and private practices.

Veterinarians wishing to become board-certified specialists typically pursue internships followed by residencies. Veterinarians wishing to become general practitioners may opt to do internships after graduation but need not; they can go directly into regular employment.

Interns generally are paid much less than associates. Market research by the AVMA shows the mean salary for interns in 2013 was $28,988, compared with $67,535 for those in their first year of private clinical practice.

The pay disparity is a chief reason behind the worry that interns may be exploited as a cheap labor source.

Moreover, completing internships alone (not following up with a residency) has not been found to boost salaries, according to the AVMA, citing a Sept. 15, 2011, article in the Journal of the American Veterinary Medical Association.

More recent data suggest internships might even impede job prospects. In its first annual employment survey conducted in 2014, the AVMA found that “veterinarians who participated in an internship or whose first employed position was in a field outside of veterinary medicine had a higher probability of being unemployed,” according to an article by AVMA economist Michael Dicks published Feb. 1 on the website DVM360.

Rising concern about the quality of internships also is driven by a perception that new veterinarians are opting more and more to serve as interns. Solid figures are elusive, but data from multiple sources point to an upward trend.

Annual surveys by the AVMA of graduating seniors indicate a near doubling of veterinarians pursuing post-graduation training between 2000 and 2013. At the start of that period, 22 percent of survey respondents who had accepted an offer at the time of graduation took internships or residencies, compared with 43.7 percent at the end of the period.

Figures from the Veterinary Internship and Residency Matching Program (VIRMP) run by the American Association of Veterinary Clinicians corroborate the picture. As reported by the AVMA Task Force on Veterinary Internships in 2011, the number of internship positions available through the VIRMP rose from 175 in 1988 to 850 in 2009. The number of applicants climbed from 473 to 1,104 in the same period.

AVMA and VIRMP figures provide snapshots of the field, but no central organization attempts to track all available veterinary internships nor the annual population of interns.

The VIRMP serves basically as a job-listing service with a computerized matching component. The website explains that it “acts as a clearinghouse for clinical postgraduate positions,” adding in capital, bold-faced letters: “There is, however, no evaluation, regulation or certification of listed programs.

AAHA’s Russak has no quarrel with internships at university teaching hospitals. “What you see is what you get. They are controlled by their institutions (and are) certainly high-end,” he said.

Private practice internships are a wholly different matter, in his estimation. Students “need to be protected from private-practice internships,” he said bluntly, referring to programs that lack quality-control standards.

Figures from the VIRMP suggest that the great majority of internships are proffered by private practices. Of 819 matches brokered by the program in 2014, 571 were in private practice and 248 were in institutions such as universities.

“Not all private practice internships are a problem; there are some excellent ones,” Russak added. “The issue is no real overseeing body.”

Regardless of the internship host, Russak believes internships are unnecessary for veterinarians not looking to specialize. “There is no reason to do an internship if you aren’t doing a residency, period,” he said.

He maintains that veterinary schools should do a better job of preparing students to be comfortable with hands-on practice from day one so they don’t feel the need for further clinical training. “If our kids spend eight years in college now, and they graduate and they aren’t ready to go out into practice and they need a fifth year of education, whose fault is that?” he asked rhetorically.

Another factor arguing against internships for those wishing to practice general medicine are the high levels of educational debt burdening most veterinary-school graduates today, Russak said.
Nine out of 10 veterinary students graduate with school debt; the average debt was $162,113 in 2013, according to the AVMA.
Owing that kind of money, it just doesn’t make financial sense to take a low-paying internship, Russak maintains. “Already you’re in the hole the first year. … In most cases, you’re going to have to wind up borrowing more money (while interning). It’s been shown by some statistics that (an internship year is) going to cost $45,000 per year.”

Dr. Tony Bartels, a member of the AAHA internship committee who also served on an AVMA Task Force on Veterinary Internships, lays out the cost of an internship this way: “Price equals forgone salary plus interest on debt plus living expenses beyond salary.”

Using this formula, he calculates $49,000 to be a conservative estimate of the cost of an internship, where the forgone salary is $38,000 and one year of accumulated interest on median student debt is $11,000. (That doesn’t account for living expenses that exceed an intern’s pay.)

Dr. Todd Tams, a board-certified internal medicine specialist who is chief medical officer of VCA Inc., oversees an internship program that trains approximately 150 new doctors each year. He has a markedly different perspective on the value of internships.

He believes mandatory internships would enhance the profession. “I wish every new graduate from veterinary school had to do an internship,” Tams said. Internship-trained new veterinarians are “more confident and competent,” he said. “They know how to move cases quickly.”

Speaking personally, Tams said he wouldn’t have traded his own internship experience for anything. He was an intern in 1978-79 at the West Los Angeles Veterinary Medical Group.

The financial sacrifice required to do an internship, Tams believes, pays off in the long run in terms of productivity and quality of life even for those not planning to specialize.

“To me, the first and foremost reason for doing an internship is to become a better doctor,” he said. “Most interns go into general practice. Someone can get in a good internship program what they would gain in three to four years of clinical experience.”

But he agrees that professional standards are needed. As such, he served on the committee that developed the AAHA internship accreditation program.

Among the sources to which the AAHA team looked when crafting standards for its companion-animal-practice members was the American Association of Equine Practitioners. The AAEP lists internships and externships hosted by member practices under what it dubs its Avenues Program.
Dr. Monty McInturff, AAEP board liaison to the Avenues Task Force, described the group’s ongoing process for developing guidelines for participating practices: “The Avenues Program does a lot of surveys — we survey member practices to ask what they are looking for, and we do exit surveys for interns,” he said.

The surveys have “helped to build some benchmarks” such as average starting salary, benefit packages, number of vacation days and number of emergency hours required of interns. McInturff views the benchmarks as a starting point for self-evaluation by the practice.

The Avenues Program doesn’t set a mandatory structure for internship programs; rather, it provides mentorship for the mentors. A coordinator works with the practices, providing negative and positive feedback from past and current interns.

McInturff agrees with Tams that a well-structured internship can help any new veterinarian develop clinical skills, leading to greater productivity. “Interns benefit by coming onto a team with established treatment plans and mentorship that they’d struggle to get on their own,” he said.

Dr. Eric Fish, a resident in clinical pathology at Auburn University in Alabama, did a university internship at the teaching hospital of Virginia-Maryland Regional College of Veterinary Medicine in 2012-13.

Fish said the salary was low at $28,500, but he considered it an investment. “My understanding is that financially, you don't recover from an internship unless you pursue a residency and become a specialist,” he said in an interview by email. “However, I always wanted to do a residency so I didn't really see doing an internship as optional, at least in terms of keeping my options open the widest.”

Fish was satisfied with the mentorship in the routine medicine and specialty services, and said the program provided ample academic support with rounds and seminars. However, he added, “There was minimal supervision on emergency shifts (weekend days, holidays, overnights). The faculty and residents did a good job going over case management on those patients that were transferred, but those that were discharged on ER slipped through the cracks.”

Fish said nearly two-thirds of his class did internships, many in private practice. While his sense is that those internship programs created strong emergency veterinarians, overall, he said, the mentorship and hours appeared to be less carefully managed than in the university.

“From what I hear, most of my classmates who did private practice saw primary ER cases, but on specialty rotations (their roles) were much more observational and (they) did lots of ‘scut work’; paperwork, mostly. Also, a lot of the ones in private practice seemed to have a much lower quality of life than I did as an intern.”

Why did so many of Fish’s classmates pursue internships? As with the exact numbers of interns and internships, solid data on what’s driving the popularity of internships is scanty. Results of the AVMA’s seniors survey in 2010 offer a clue to what motivated that year’s graduates.

As described in the AVMA Report of Task Force on Veterinary Internships, about 42 percent of those accepting internships planned to apply for a residency after completing an internship, 31 percent wanted to practice better quality medicine and 17 percent believed they needed additional training before entering practice.

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