Photo by Scott Nolen
A movement to eliminate the requirement that veterinarians conduct a hands-on exam before diagnosing and treating a patient leads Dr. Mark Helfat to worry that — what with the rise of telemedicine and artificial intelligence — veterinarians may one day never actually touch their patients.
I have a question for fellow veterinarians: What inspired you to apply to veterinary college? What motivated you to complete that grueling academic pursuit? Me, I counted the days until I might palpate and auscult, lay my hands on the animal, use my senses, and foremost, heal. Forty-five-plus years later, that still is what drives me. Whether in a stanchion, stall or exam room, it is the physical one-on-one that defines me as a veterinarian and that uniquely bonds me to patient and owner.
Another question: Do you ever ponder the future of veterinary medicine and think about where this pursuit will find you in 10 years? Personally, as of late, when I consider the future of veterinary medicine and its delivery, I grow nervous and fraught with despair.
I see three looming circles set to converge: telemedicine, artificial intelligence and the dilution/deletion of our veterinary-client-patient relationship (VCPR). As these three trends gain momentum, I fear that our doctorate of veterinary medicine may become a pathway to doing almost nothing but sitting behind a screen and "examining" a patient who is miles away.
Free advice vs. telemedicine for a fee
Telemedicine, circle No. 1, is touted for its expedient delivery of health care. Thanks to Covid-19, this modality surged in popularity and found its niche like never before. The internet now provides health care. Its cheerleaders claim that online health care is more affordable, easier to deliver when compared with the traditional office visit and the answer to the present workforce shortage.
I read a recent VIN News Service interview with Dr. Aaron Smiley, who is a founding board member of the Veterinary Virtual Care Association. While I understand Dr. Smiley's enthusiasm for telemedicine, I harbor major reservations regarding his perspective on monetizing this modality.
My thought is that I already provide telemedicine and have for many decades — absolutely free. Numerous times a day, my staff and I chat by phone with clients and potential clients, listening to their concerns and advising them of a reasonable plan. But those conversations usually conclude with the booking of an in-person visit as needed.
This happens regularly in my practice: The receptionist will hand me three or four messages a day — Westie with itch, cat coughing, Frenchie with the poops, kitten vomiting. I study the problems and instruct a veterinary technician to return the calls with a set of follow-up questions. Depending upon the responses, either simple at-home remedies are suggested or appointments are recommended.
For those who are seen in the clinic, I commonly instruct clients to call me in X days with an update on the patient's condition. There is no need to drag them back into the office if all I need to know can be ascertained with a five-minute conversation.
I suppose you could charge for these consults and call it "telemedicine." I prefer to refer to it as "free advice," with the caveat that an in-person examination may be necessary to fully treat the patient. After all, there is nothing like an in-person visit to establish and maintain trust, evaluate the whole patient and provide the highest standard of care.
With regard to the "ease" of telemedicine's delivery for those who may not be able to travel to the veterinarian, I ask: Can you spell M-O-B-I-L-E V-E-T-E-R-I-N-A-R-I-A-N?
As for serving those who live miles and miles from a veterinarian, I understand the convenience of a telemedicine consult for them, but I continue to come back to the benefits of an in-person physical exam for everyone else, who make up the great majority of pet owners.
Regarding the workforce shortage, all I read about is one new veterinary college after another, not to mention growing class sizes at established programs.
Moreover, you don't have to be a genius to foresee that the pet population that boomed during Covid is set to return to normal numbers. Will we, in fact, face a future veterinary oversupply? Don't laugh. I recall a downturn circa 2010 that saw such a situation. I urge you to read the recent American Veterinary Medical Association article Straight talk about veterinary workforce issues. This informative piece by outgoing AVMA President Dr. Lori Teller succinctly debunks workforce shortage fears.
What frustrates me most about telemedicine is its potential influence on what we call standard of care — a legal term that refers to the level of care, skill and treatment recognized by health-provider peers as acceptable and appropriate. If we adopt telemedicine wholesale, we will need to revise our understanding of the standard of care as it relates to the patient visit. We will be bound by a new understanding whereby the veterinarian is no longer held to the traditional thorough and complete physical exam. Bluntly, the standard of care for a telemedicine exam will have to drop several notches to accommodate the inability to fully evaluate the patient.
Shouldn't our profession seek to elevate its standards, continually striving to raise the bar — not lower it?
AI as an accelerant of change — for better or for worse
Circle No. 2, AI, is all over the news as it collects geometric proportions of data with incredible speed. Can you picture the ability of this ravenous tool to diagnose, prescribe and plan a treatment once it absorbs the reams of veterinary information available to our profession? Freely available sources run the gamut from the latest veterinary textbooks to lectures/continuing education to case studies to classroom notes to ultrasound/radiograph instruction and on and on and on.
How quickly AI will become a daily part of our lives is anyone's guess, but the digital revolution suggests it won't be too long. That smartphone you sport has exponentially more power and memory than the computer system on Apollo 11. I read that the Apollo guidance computer, which enabled the first man-on-the-moon landing in 1969, would not even have had the ability to store an article of this length. Yes, that was more than half a century ago, but the rate of computing advancement appears to be accelerating. Think about the smartwatch. Imagine the personal health data it will be able to monitor just five years from now.
I recognize that AI is here to stay. I am not a Luddite. My point is that AI will affect veterinary medicine — along with an untold number of other occupations — dramatically, emphatically and irreversibly. Our challenge as practitioners will be to adapt to the impact of AI and understand how we may use it to our advantage. The next generations of students will no doubt take courses on the subject.
Losing the foundation for building trust
Circle No. 3 is the one I most fear. The VCPR (veterinarian-client-patient relationship) as we know it lies on the chopping block. If state boards of veterinary medicine and legislators continue to be swayed by arguments to remove the need for an in-person examination in order to establish a VCPR, we could descend into a world where we never actually touch our patients, thus denying them the diagnostic benefit of a complete physical exam.
From decades of practice, I've learned that the one core value that's foremost when consulting with clients is trust. When trust exists between the client and veterinarian, each fully understanding the other, the patient receives the best care. It is far easier to communicate and bond with your client — to build trust — when you are in the same room, breathing the same air, than through a distant conversation over phone or video.
On occasion, I see a patient whose earlier veterinary care was obtained only at a so-called "vaccination clinic." I cannot adequately express the amazement in the client's eyes when a thorough physical examination of their pet uncovers a condition that previously had gone undiscovered. Whether the finding is rotten teeth, heart murmur, breast tumor or mites, using all the senses epitomizes what I signed up for as a doctor. Perhaps this is why we traditionally refer to the practice of medicine as a science and an art.
I cannot bear to think that we will someday lose the face-to-face consultation that defines the veterinarian as hands-on and uniquely trained to examine patients who do not speak, yet despite this challenge, delivers an expert diagnosis and treatment plan.
Should we lose the initial in-person requirement, some clients might never see the inside of an animal hospital. They might never know the warmth and familiarity of a physical veterinary facility. I submit that there is no substitute for the welcoming smile of a receptionist or the caring concern of a technician.
I have clients who make their first appointment as a get-to-know-you visit. Their pet is not due for vaccines, and there are no health issues — they simply want to acquaint themselves with our staff and get a feeling for our office. Their goal is to confirm their decision in choosing our hospital and entrusting the care of their pet(s) in our hands.
To witness this over and over solidifies my belief in the initial in-person visit requirement. This first visit to a real veterinary facility lays the foundation for all future visits. I believe that the R in VCPR — relationship — alludes to a special bond that can originate only when in the same physical space.
Here is what I imagine when the circles of telemedicine, AI and the weakened VCPR converge: A pet has an initial visit remotely. The veterinarian who consults suspects bladder stones and recommends an ultrasound or radiographs. A technician performs the diagnostic procedures. An AI program delivers the findings with total accuracy.
Did a veterinarian actually touch the patient? Thank goodness we will still need surgeons! At least for a while.
For those who share my concerns, take heart. The future is defined by what we glean from the past and resolve in the present. If you agree on the need to maintain the VCPR that has stood the test of decades, let your voice be heard. Contact your state veterinary medical association, your state legislators, your state Board of Veterinary Examiners, your colleagues. Tell them your concerns. Speak up!
Mark P. Helfat graduated from Cornell University College of Veterinary Medicine in 1977. He owns and practices at Larchmont Animal Hospital in Mt. Laurel, New Jersey. He has volunteered for veterinary organizations and institutions for most of his career (New Jersey Veterinary Medical Association, American Veterinary Medical Association, Cornell University College of Veterinary Medicine, Virginia-Maryland College of Veterinary Medicine). Mark and his wife, Mendy, share their home with four beagles and many cats.