October 01, 2012

 

 Where to draw the line

Rural practitioners debate role of veterinary technicians

 
 
Posted on September 19, 2012
 
 
Dr. W. Mark Hilton is big on delegating responsibility to well-trained veterinary technicians.
 
“It makes them happier, because they’re doing a higher level of work than they were doing before. The client is positively impacted, and someone is doing the job just as good as I was, maybe even better,” Dr. Hilton said. “And I’m allowed to do more veterinary medicine and not as much technician work. ...  We don’t use (technicians) to their fullest capacity. We have them doing jobs that an unlicensed assistant could be doing.”
 
Veterinary technician Danielle Glynn castrates a calf while her employer, Dr. W. Mark Hilton, looks on.
Courtesy of Dr. W. Mark Hilton
 
The professor of food animal production medicine at the Purdue University College of Veterinary Medicine points to his farm calls processing beef cattle with his technician, Danielle Glynn, as a good example. They have two chutes running—cows are walked through one chute and calves through another. He palpates, and she vaccinates and provides whatever else is necessary.
 
“We’re done in half the time, and everything gets done properly,” Dr. Hilton said.
 
He continued, “We get so busy doing the routine things that we don’t take time to consult with an owner, like (saying), ‘You’ve been buying more calf scours medicine lately; let’s talk about that.’ But if we have another call to go to palpate 100 cows, we’ll talk about it next time. Whereas a technician, if she’s dehorning and castrating while you’re palpating cows, then you have another 30 minutes to talk to the owner about something that’s very much going to impact his business.”
 

Filling in the gaps

The demands on today’s food animal producers are different from even a decade ago because of changes in livestock density as well as location and numbers of farms. This has translated into a more geographically dispersed clientele for some rural veterinarians, sometimes leaving them to struggle to maintain practice viability and client profitability.
 
A recommendation in the National Research Council’s study for the National Academy of Sciences, “Workforce Needs in Veterinary Medicine,” released May 30, stated: “... to increase the value of veterinary services in large, intensive livestock and poultry producers, the education of food-animal practitioners should be reoriented toward herd health and improving the productivity of farm operations. In rural areas, where primary veterinary care is needed but there are too few farms to support full-time veterinarians, a system of animal health care involving rigorously trained technicians under the supervision of veterinarians could be developed.”
 
Dr. Sheila W. Allen, dean of the University of Georgia College of Veterinary Medicine and member of the NRC report committee, said the idea is to allow paraprofessionals to have more responsibility the way nurse practitioners and physician assistants in the human health field do now, handling more routine aspects that don’t require the knowledge of a veterinarian, such as collecting blood samples or administering vaccines. Meanwhile, veterinarians would be freed up to talk with producers about such things as becoming more feed-efficient, analyzing records, and controlling infectious diseases.
 
The report recommends “the AVMA and the professional associations of food-animal practitioners will need to enter a dialogue with officials to modify state practice acts to permit credentialed veterinary technicians to administer livestock health services provided that they are subject to oversight by (and in constant communication with) licensed practitioners who may be in distant locations.”
 
Dean Allen said, “This is not new. It’s something we’ve been talking about for a long time. Maybe now is the time we pull the trigger and do it. It will require leadership in saying, ‘Let’s draft a model practice act’ and all states could do it. States could convince legislators so the needs in rural areas could be met.”
 

Flexibility needed

Currently, definitions, lawful duties, and corresponding levels of supervision vary among states, from those that don’t delineate duties that require a license to those that recognize and define registered veterinary technicians.
 
Veterinary technician students at Purdue University practice their phlebotomy skills during a dentistry laboratory.
Courtesy of Dr. Pete Bill
 
The AVMA has stated in its 2012-2015 Strategic Plan, under the “Advocate Oversight of Veterinary Medical Procedures” goal, that one of its objectives is to “support and develop models, in consultation with state associations, for legislation and regulations that require veterinary oversight of paraprofessional training and paraprofessionals’ performance of designated veterinary medical procedures.”
 
That said, Adrian Hochstadt, AVMA assistant director of state legislative and regulatory affairs, is not aware of any immediate plans to change AVMA policy in this area. He noted that the existing AVMA Model Veterinary Practice Act provides flexibility in the type of supervision that a state may choose for technicians working with veterinarians. For example, Section 6 of the model act provides an exemption for “any credentialed veterinary technician, veterinary technologist, or other employee of a licensed veterinarian performing lawful duties under the direction and supervision of such veterinarian who shall be responsible for the performance of the employee.” Under this language, Hochstadt said, a state may require less than direct supervision, if the legislature concludes that a veterinary shortage exists in certain areas.
 
In some cases, legislation has been introduced to allow credentialed veterinary technicians—a broad term that can indicate the person is licensed, registered, or certified—to work on their own in providing certain veterinary services for existing clients of their employing veterinarians. The rationale is that allowing such veterinary paraprofessionals to provide certain animal health services differs from allowing laypersons to do the same, because credentialed technicians have applicable knowledge beyond laypersons. Plus, they generally are in direct communication with a veterinarian.
 
AVMA President Douglas G. Aspros told JAVMA News that credentialed veterinary technicians are an integral part of veterinary practice today and that it’s clear they can extend the reach of veterinarians in providing services to animals in a variety of situations. How they are used will develop over time, he said.
 
“The flexibility of the model practice act is appropriate because different states and different practice settings and animal settings are going to require different solutions,” Dr. Aspros said.
 

Observing versus diagnosing

A few states have taken the initiative to allow greater responsibility for their credentialed veterinary technicians.
Maryland’s legislature passed a bill in 2011 that excludes from the practice of veterinary medicine the performance of certain procedures by a registered veterinary technician when under the direct supervision of a veterinarian, including administering anesthesia and medications, extracting teeth, and suturing.
 
The Alaska Board of Veterinary Examiners approved several changes in the past few months to its veterinary practice act regulations, including allowing a veterinary technician to provide care to an animal under “remote direction” in communities that do not have an established veterinary practice.
 
 Indiana, in 2009, went one step further and passed an amendment that allows registered veterinary technicians to perform routine food animal management practices under direct or indirect supervision of a veterinarian if a valid veterinarian-client-patient relationship exists. That means a technician has the legal ability to work within the clinic or farm, for example, without a veterinarian actually being physically there.
 
“The veterinary technician, then, is acting as an extension of the veterinarian for routine farm care, but in our law ... the veterinarian already has a relationship with the livestock producer, and it’s important that is already established. So, it’s not that the technician is going in place of the veterinarian, especially if a diagnosis, prescription, or surgery is required. That’s the responsibility of the veterinarian,” said Dr. Pete Bill, director of the Purdue University Veterinary Technology Program and a former member of the AVMA Committee on Veterinary Technician Education and Activities.
He chaired the Indiana Veterinary Practice Act Committee at the time and strongly advocated for the amendment. Dr. Bill acknowledged that veterinarians have to be careful with how technicians are deployed so they understand their role as observer of clinical signs versus a provider who makes a diagnosis or prescribes treatment.
 
“One of the big fears (of veterinarians) is that technicians will go off and start their own business or do veterinary medicine without being properly supervised. There is this fear that we are giving away services. If you think about it, we’re not. If we do this right, we’re expanding and leveraging the ability of veterinarians to reach those folks in underserved areas at a little more cost-effective rate,” he said.
 
Passive range-of-motion exercises being performed by registered veterinary technicians Abby Rafferty and David Sessum after removal of a splint
Courtesy of Scott Birch/Texas A&M University College of Veterinary Medicine & Biomedical Sciences
 
Ideally, the technician would have completed a bachelor’s degree program rather than an associate’s degree program, Dr. Bill said, so they would have had more opportunities to receive additional experience and education in herd health. Of the 203 veterinary technology programs accredited by the AVMA Committee on Veterinary Technician Education and Activities, 22 offer four-year degrees, including Purdue.
 
“The key things are veterinary technicians having the education to do it, having the legislation to allow them to do it, and getting a system in place that’s acceptable to both veterinarians and the public for being able to implement that service,” Dr. Bill said.
 

Potential drawbacks

Some states haven’t bought into the arguments for allowing paraprofessionals to provide services on the farm without direct supervision.
 
A few years ago, a proposal in Colorado would have created a category of  “certified food animal veterinary assistants” to deliver livestock health care and diagnostic services as approved by, and under the direction of, a veterinarian, without requiring the practitioner to be on site.
 
Colorado’s state veterinarian, Dr. Keith A. Roehr, and his office laid out their opposition to the proposal in a February 2010 Colorado Department of Agriculture Animal Industry Division newsletter.
 
They said that individual animal and herd health might actually be adversely affected by allowing paraprofessionals to perform veterinary procedures, because paraprofessionals would not be as well-trained as veterinarians. Plus, certain concurrent diseases or conditions might go unnoticed by a paraprofessional until clinical signs were more obvious to the producer or until a veterinarian were involved. Further, his office said that sending paraprofessionals in place of veterinarians would decrease surveillance for livestock diseases, because veterinarians are the eyes and ears of the state veterinarian’s office.
 
“If paraprofessionals are allowed to take away some of the veterinary work, the veterinarian’s role in providing that first line of defense to protect the food supply will be diminished,” according to the newsletter.
 
Further, Dr. Roehr argued, producers would not get the advantage of the veterinarian’s education and expertise when veterinary procedures were performed and might discover it harder to find a veterinarian when they needed one.
 
As for veterinarians, Dr. Roehr’s office contends they would suffer, too, because allowing paraprofessionals to perform veterinary procedures and practices would reduce livestock veterinarians’ income. He also rejected the notion that veterinary medical practice can be compared with medical practice in which licensed paraprofessionals are used successfully, because the U.S. health care system is based on a third-party payer system.
 
“Veterinary incomes are greatly influenced by supply and demand. Loss of revenue for veterinarians will have a negative impact,” according to the newsletter.
 
The Colorado VMA also opposed the proposal, saying that the notion that a paraprofessional could perform all procedures with the same skill and competence as a veterinarian is unrealistic. Another argument brought up in the CVMA’s position statement published Sept. 14, 2010, stated: “It is unlikely that confined animal feeding operations, which already train their own employees to perform some of the procedures described in the proposal, would pay more for these procedures to be done by a paraprofessional and schedule work around the paraprofessional. (The Colorado Veterinary Practice Act) clearly allows employees of the animal owner to perform these procedures.”
 
Ultimately, the proposal to allow paraprofessionals to perform routine livestock procedures and practices did not make it into the state practice act. But more recently, the Colorado State Board of Veterinary Medicine promulgated a regulation defining situations in which “indirect supervision” is acceptable, so long as there is a suitable written protocol established by the licensed veterinarian designated as responsible.
 

Taking another look

Other states have yet to decide on the issue. For the past few years, veterinarians in Texas have wrangled over whether to allow laypersons to float horses’ teeth. Ultimately, a bill was passed in the legislature allowing for state-licensed “equine dental technicians” to operate under the supervision of a licensed veterinarian.
 
David Sessum, president of the Texas Association of Registered Veterinary Technicians, said that law has spurred interest in further changes to the Texas Veterinary Practice Act.
 
The Texas VMA created a task force this past year to look into whether the Texas State Board of Veterinary Medical Examiners should start licensing veterinary technicians. Currently in Texas, credentialed technicians are classified as registered veterinary technicians, which is a voluntary registration. The task force is looking into licensing technicians and requiring them to be licensed to call themselves a licensed veterinary technician.
 
Sessum gave a presentation on the task force’s findings at the September TVMA board of directors meeting. If the TVMA gives the go-ahead, the TVMA and Texas State BVME will start lobbying to modify the practice act during the 2013 state legislative session.
 
Other changes the two groups are considering are whether to allow credentialed veterinary technicians to supervise noncredentialed technicians or to allow for indirect supervision of a technician by a veterinarian.
 
“We’re trying to make it advantageous to be a credentialed technician and for a veterinarian to employ credentialed technicians without changing the scope of practice as it is now,” Sessum said.
 

Undecided but interested

Dr. Brian J. Gerloff, president of the American Association of Bovine Practitioners, said there’s no consensus within his association’s membership on this issue. The AABP considers the topic important enough, though, that it had two sessions on the use of technicians in cattle veterinary practice during its annual convention Sept. 20-22 in Montreal.
 
“Some veterinarians feel strongly that the use of veterinary technicians, to large degree, will only dilute the opportunities for veterinarians to earn income. On the flip side, a number of veterinarians look at this as a way for veterinary practices and rural veterinarians to leverage their time more effectively and enhance their ability to offer services and make an income,” he said. “Part of the key is being paid by the producer for that vaccination more than you’re paying the technician, yet have it done in a way that’s cost-effective for the producer.”
 
Dr. Gerloff said feedlot practitioners have been a step ahead in their approach to the new reality of production medicine. They have been using technicians to walk the hospital pen or transmit necropsy pictures back to the central office.
 
He himself used to own a veterinary practice but now works full time as a nutritionist. He said that nutritionists generally work on a retainer basis, charging per head of cattle per day, which he thinks is something food animal veterinarians could consider.
 
“It’s still uncertain and evolving, the shape of successful rural practices in the future, that is,” he said, adding that the AABP recently sent out an economic survey form to its members. “From that data, maybe we can identify successful practices that might open further discussion that will include technicians or not.”
 
“Some veterinarians feel strongly that the use of veterinary technicians, to large degree, will only dilute the opportunities for veterinarians to earn income. On the flip side, a number of veterinarians look at this as a way for veterinary practices and rural veterinarians to leverage their time more effectively and enhance their ability to offer services and make an income.”
Dr. Brian J. Gerloff, president, American Association of Bovine Practitioners 

  

Further considerations

Even if veterinarians agree that increased use of veterinary technicians will help their practices, they may have another problem on their hands: finding and retaining credentialed technicians.
 
Deana Baker, a certified veterinary technician and president of the Wyoming Veterinary Technician Association, said the same problems that affect veterinarians in rural areas also affect technicians. These include low wages, poor housing choices, being on call 24/7, a lack of work for a spouse in the area, a veterinarian who is “difficult” to work with, underuse of the technician’s skills, lack of quality child care in the area, and inadequate large animal training through their particular program.
 
“You also have to remember that many new techs have student loans. Many techs have gone through private programs. Some new grads have $20,000 to $25,000 loans,” Baker said. “While this doesn’t seem like much when compared to graduate veterinarian loans, keep in mind that most techs in rural areas seem to start out at close to minimum wage.
 
“Plus, many technicians are attached to a spouse. In many cases, the technician is not the primary breadwinner.  So, unless they are moving back to the area because they have family ties, they most likely will move to an area that has a better job market.”
 
At this time, a number of practices in Wyoming are having difficulty hiring credentialed technicians, as there are not enough to serve all of the veterinarians in the state. Baker knows of four practices in Casper that are actively seeking CVTs as well as one practice in Jackson and one in Sheridan.
 
Because of this situation, many veterinarians have hired assistants and trained them to act as technicians, she said. This is legal in Wyoming, and even with proposed changes to the state veterinary practice act, it will be legal. The WyVTA is lobbying for regulatory changes so that the credentialed technician title would be defined, but with no specific duties identified,  other than a statement that no surgery, prescribing, or diagnosing would be allowed. The WyVTA would also like to hand over the credentialing process to the state. 
 

In need of study

At its core, the debate over use of veterinary technicians involves both medicine and economics. The veterinary community and animal owners strive for healthy animals. Yet, this common goal is sometimes hindered by veterinarian availability, underuse of veterinary services, or unfavorable cost-benefit ratios.
 
The AVMA Executive Board, recognizing that the Association needs to further address workforce and economic issues such as this, has taken steps to do so. In April, the board approved using up to $330,000 from the AVMA National Economics Strategy Fund for a workforce study proposed by the AVMA Veterinary Economics Strategy Committee. The study will identify, quantify, and evaluate various economic, demographic, technologic, and sociologic factors influencing the supply and demand for veterinarians and veterinary services across the nation.