March 01, 2020

Work on farms and in clinics provides future veterinarians valuable experience, but allowing students and other nonemployees to work or volunteer in a veterinary practice can raise concerns about potential liability.

AVMA leaders called for guidance and education during a discussion on the use of students, externs, and volunteers in veterinary practices. The discussion was part of the Veterinary Information Forum, a series of short discussions on priority topics for the AVMA House of Delegates.

Other topics included the current status of cannabidiol-containing products in veterinary medicine and ongoing AVMA efforts to encourage the use of telehealth services while maintaining standards of care. The delegates met Jan. 10-11 in Chicago as part of the AVMA Veterinary Leadership Conference, a combination of AVMA governance meetings and professional development sessions.

Student lawsuit

In 2017, a Missouri jury found a veterinarian and a cattle owner each partly responsible for injuries suffered in 2009 by a then veterinary student who was vaccinating cattle on a farm when a calf crushed her hand against the wall of a cattle chute. The jury also found the veterinary student partially responsible. A state appellate court affirmed the decision in March 2019.

The appellate court ruling states that the student was working with a farm worker who was unauthorized to supervise her. That farm worker did not properly restrain the calves for vaccination and responded in anger to the student’s safety concerns.

An unrestrained calf jumped and crushed the student’s hand, the court file states. She suffered a carpal bone fracture and, according to the ruling, developed chronic conditions associated with arm and shoulder pain.

A jury decided the cattle operation was responsible for $3 million in damages and the supervising veterinarian for $1.2 million.

Dr. Jim Brett, a representative on the House Advisory Committee, said volunteer work and externships with private practitioners have great educational value, noting that veterinary colleges consider such work experience when evaluating admission applications and that some colleges with distributed education models rely on partnerships with private practices to teach clinical skills.

Dr. K. Fred Gingrich II, executive vice president of the American Association of Bovine Practitioners, said some veterinarians seem to be uncertain about whether their insurance covers injuries to volunteers and externs. He also said the potential legal liability risk may discourage cattle-owning clients from allowing student volunteers to work on their animals.

He wants education on what veterinarians should do when a student is injured, as well as what veterinarians can do to reduce their legal risk.

A grey area

Dr. Andrew Maccabe, CEO of the Association of American Veterinary Medical Colleges, said in a reference committee meeting that while the Missouri student’s lawsuit was a singular case, it was an important one that highlighted and caused veterinary leaders to pay attention to what has been a grey area for many practitioners or one that many may have been unaware of.

The opportunity for (veterinary) students and prevet students to shadow is valuable and benefits the profession. But we need to ensure there is appropriate oversight and safety and personal injury and liability issues are covered, so that when accidents do happen, there isn’t an uncovered liability people are responsible for.

Dr. Andrew Maccabe, CEO, Association of American Veterinary Medical Colleges

“The opportunity for (veterinary) students and prevet students to shadow is valuable and benefits the profession. But we need to ensure there is appropriate oversight and safety and personal injury and liability issues are covered, so that when accidents do happen, there isn’t an uncovered liability people are responsible for,” he said.

He noted that, in general, if a student is injured while engaged in an activity overseen by a veterinary school through a formal relationship with a private practice, the student would generally be covered under the university’s insurance policy.

This is the situation, for instance, for practices that participate with a veterinary school in a distributed education model. “Those are where employers are often paid to take students, and the employers may be considered adjunct faculty usually. That’s a high order, and those are well regulated,” Dr. Maccabe said.

The situation may be less clear for practices that offer externships or clerkships as an elective or for no credit. At many schools, he said, the associate dean’s office has a list of several practices with which the veterinary school has an agreement outlining how the practices will manage students, but these may not address potential legal liability issues.

However, grey areas can arise when students and practices engage in informal arrangements, even if it’s with a student who previously worked at the practice through a school-sanctioned program. This is also true when preveterinary students seek out opportunities to shadow a veterinarian on their own and when individuals volunteer in clinics.

Marie Bucco, Student AVMA president, said this may be an opportunity for SAVMA to educate students, too, by working with the American Preveterinary Medical Association to develop an FAQ or checklist.

“Most students assume they’ll be covered or things will get taken care of,” she said. As a former prevet student, she said, she would have just accepted it as her own fault if an accident occurred. “But it would be good to remind students to ask questions at a practice you’re about to shadow.”

In an effort to better understand and address these issues, the HOD recommended that the AVMA Board of Directors consider the development of a toolkit, including potential forms, and an awareness campaign for the protection of practitioners, students, and other members of the veterinary health care team.

Cannabis and telehealth

Introducing the discussion on cannabis-derived products, Dr. William Flynn, deputy director for science policy in the Food and Drug Administration’s Center for Veterinary Medicine, said the agency is deliberating how to manage or regulate such products, which have not been approved as food additives or for therapeutic uses in animals. CBD has some recognized clinical benefits in humans, but many unanswered questions and safety-related data gaps remain, he said.

Some data raise concerns about potential harm to animals, especially toxic effects on the liver and male reproductive organs, Dr. Flynn said.

FDA officials issued warning letters to 22 companies that sold illegal CBD products in 2019; 15 of those companies were selling such products for use in animals.

Delegates indicated they want guidance and leadership from AVMA on how to approach use of products.

Marijuana is legal in 11 states for recreational use among adults over the age of 21 and legal for medical use in 33 states. State veterinary medical boards have given varying direction to veterinarians regarding communication with their clients.

Dr. Mike Jones, delegate from Oklahoma, said in a reference committee meeting that since his state legalized medical cannabis in October 2018, pet intoxication is astronomical now.

“These dogs are stumbling in the exam room and peeing all over the place. I’ve been at it 29 years, and this is new. We’re seeing one to two a week in practice,” he said. “The dogs don’t eat just one, they eat the whole bag. … Back in the days when it was illegal, you used to hide it, but now it’s out and legal to have,” and pets can get into it more easily.

Dr. Melanie Marsden, District IX AVMA Board of Directors representative, said practitioners in her state of Colorado also saw a spike in marijuana intoxication after the drug became legal recreationally in 2014. She said: “Now, I see (intoxication) maybe once every few months. I don’t know if it will be similar, but that has been our experience.”

In telehealth, AVMA staff and volunteer leaders indicated many pet owners want more options for reaching veterinarians from a distance, and veterinarians are increasing their use of remote consultations with specialists. Whether veterinarians can establish a veterinarian-client-patient relationship without an in-person examination remains a source of debate.