ance through the organization of the health Learning should be based on problem solving care system. by taking real or simulated patients problems, We are now entering the golden age of then working them down to the cellular and community medicine. Society in its wisdom will molecular level, and out to the broad personal, give the generalist equal financial rewards and family and societal levels. equal social recognition so that at cocktail To do this the family physician or generalist parties one will not be asked, 'What is your must have equal academic status in the Unispecialty, doctor?" It becomes necessary versity and must serve as a role model for stuthrough legislation and financial control to limit dents and young physicians. The government the number of specialists proportionate to the of Ontario has indicated that 50% of the output needs of society. of our medical schools shall go into primary The health care system must be organized care to meet society's needs. Today health care so that it is based on a system of primary care. is becoming rapidly less hospital centred so This means comprehensive, continuing, family that in the future our people can work forward centred health care by family physicians or to continuing, comprehensive, available, ecogeneralists working in a health team with all nomical and high quality care in the age of the other professionals referred to earlier. The community medicine. specialist can then see appropriate problem What advice would I give to a profession cases on referral from the primary care sector. entering an age of specialization? The fully developed system would have primary care relating to secondary care, which 1) Accept the necessity of specialization. includes the general specialist in broad areas 2) Keep it in its place by recognizing that the such as pediatrics, psychiatry. Tertiary care is generalist's task is more difficult and demandmade up of the sub-specialist in the narrower ing and capable of handling the vast majority area usually requiring a great deal of gadgetry, of problems. high costs and a hospital setting. 80% of pa- 3) Control the numbers of specialists, and tients' illness requires primary care, 19% sec- make sure the social and financial rewards are ondary care and 1% tertiary care. equal. To facilitate such a system medical educa- 4) Plan now for the future. Determine the tion must assume a different format with the future pattern for delivery of veterinary care introduction of students to patients at an early and make sure the education of students prestage in the primary ambulatory care setting. pares them for the future.
SPECIALIZATION IN VETERINARY MEDICINE VIEWPOINT OF A GENERAL PRACTITIONER P. A. Doig* IT IS A PLEASURE for me to be with you today for Probe '75 and the discussion on specialization in veterinary medicine. As a general practitioner I am happy to participate and put forth my views. Hopefully in the discussion I will adequately represent this large group of practitioners who I believe may be a forgotten group as our profession races towards specialization. It is important that a general practitioner have a chance to speak, and I thank you for the opportunity. When first requested to speak I was asked to point out "why it may be unhealthy for us as a profession to over-specialize and why we 'P.O. Box 1150, Aylmer, Ontario
should stress more diversification". I was a little surprised to find that the subsequent title given for my presentation was "Hold It - Specialization Is Not Needed". My first reaction was "Hold it, that's not what I wanted to say". No one could sensibly argue that some degree of specialization is not required in our profession. Specialists are obviously needed at the academic level, as resource personnel, in research, and in the various disciplines such as pathology, anatomy, physiology or microbiology. There is also a need for specialists in clinical practice and in this area the practicing veterinarian tends to specialize according to species. With the exception of large multipleman small animal practices, I see very little
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application of body system or discipline specialization in practice. For this presentation I will confine my remarks to clinical specialization as it applies to both the post-graduate and undergraduate level. I have no particular argument against post-gradaute specialization, only a few reservations which will be outlined later. My main concern with specialization at the present time is that as we preach its benefits and exalt it to the highest, many undergraduate students also have come to believe that they too must choose a species and specialize even before graduation.
Specialization or Restriction? The Funk and Wagnalls Standard Dictionary (1) defines a specialist as "A person devoted to some one line of study, occupation or professional work". Since this definition would apply to a plumber or chiropractor, I have attempted to define "specialist" as it applies to human and hopefully veterinary medicine. In my opinion a specialist is "an individual who has carried out advanced studies in a chosen field and is recognized by his peers as having achieved a satisfactory level of excellence in that field". In veterinary medicine the term specialist tends to be used in the Funk and Wagnalls tradition with no particular reference to either advanced study or recognition by peers as having achieved any level of excellence. The only criteria apparently required to be called a specialist is simply to restrict oneself to one or two species. It is recognized that many individuals who have restricted their practices have indeed attained, by any criteria used, the specialist classification. The point is that we cannot differentiate these individuals from those who have restricted themselves and have done little or nothing to improve their skills. As yet, with species specialization, we have not reached the sophistication of yogurt. At least there we can look for the "Quality Chek'd" variety. Let us not confuse the term specialization with restriction. We should reserve the term "specialist" for those who have undergone further study and have successfully completed examinations required for certification as is the case with the various Boards for Surgery, Radiology, Pathology or Clinical Pathology. Thus far in veterinary medicine we have followed the tradition of human medicine and have certified specialization only in the various disciplines. What is obviously needed is legitimate species specialization complete with some type of certification. For this we have no
precedent in human medicine for obvious reasons. Since we do not have legitimate species specialization, for the remainder of this presentation I will use the term specialization to refer to restriction with some, as yet undefined, improvement in quality. Post Graduate Clinical Specialization There can be little argument against post graduate specialization by an individual if it results in a better professional practitioner. Many individuals may find that their interests are directed toward one or two animal species. If their geographical location or other circumstances allow them to restrict and specialize then no one could argue that they should not. However, there are a large number of practitioners who cannot or do not wish to restrict themselves. This large group of general practitioners outnumber the specialists in Ontario by a significant margin and indications are that even more are needed. One has only to open a journal to find requests from small communities for a veterinarian to settle in their area. It has been stated that the future large animal or general practice will be a large multiple man operation wvith each veterinarian developing a species specialty (3). While this may be the optimal situation and will no doubt occur in some areas, I do not see a rapid swing away from the two or three man general practice. This is particularly true in areas such as southern Ontario with its intensive and diversified animal industry. In this area both the farmer and the pet owner desire that a veterinarian be located in their communitv just as they do a physician or a dentist. In many general practices of this type, equine, dairy, beef, swine and small animals are represented. Each species will not support a corresponding specialist. The answer would therefore seem to be to join practices and centralize facilities with species specialists serving a larger area. This too would become unworkable since centralization would only increase the already critical productive time loss that results from driving to and from calls. Many owners would also be upset at losing their local veterinarian. As well, many general practitioners, like myself, no doubt actually enjoy the variety of general practice. If given the opportunity to restrict and specialize, many would not wish to do so, nor would they necessarily know which species to choose. The argument against general practice is that the veterinarian cannot possibly be well
infonned on all of the diseases that occur in the variety of animals presented to him. The answer to the argument is that the general practitioner doesn't have to be proficient in all areas. He must be familiar with the common and routine disease entities of all species and recognize his limitations with more difficult cases or procedures. It could be said that the general practitioner "specializes" in the common diseases of a number of species. Every general practice is close enough to a major city to allow referral of difficult small animal cases to a small animal practitioner. The same is generally true for equine patients. In central and western Ontario we are fortunate to be able to refer cases to the Ontario Veterinary College and faculty members are only a phone call away for immediate consultation. As well, in Ontario, the general practitioner is supported by an excellent Veterinary Services Branch. Specialists are available in swine, poultry, furbearing animals, clinical pathology, pathology, microbiology, as well as livestock specialists in all of the major large animal species. No general practitioner should feel that he must "go it alone" with any patient or herd problem. If more backup specialists are needed, they are required only in the various large animal species as clinical consultants available for the practitioner to call on for assistance. In spite of the desire or trend toward multiple specialist type practices, I am sure that the two or three man general practice will persist. General practice in veterinary medicine could be compared to family practice in human medicine and should assume a comparable position in our profession. If we recognize that there is a need for general practitioners, are we prepared to recognize and upgrade general practice as a specialty group with the same importance as other areas? The main purpose of specialization should be to improve the quality of the practitioner. If this is the case, how can we ignore the largest group of practicing veterinarians. General practice is rarely mentioned in discussions regarding the formation of specialty groups for the maintenance of excellence or for improving the quality of the practitioner. And yet, general practice requires as much cranial output and continuing study to remain competent as any restricted area. The quality of members could be significantly improved with their own association in which continuing education courses would be designed specifically for the general practitioner. It would appear that the trend toward increased numbers of urban students in the
undergraduate program will provide for adequate numbers of small animal clinicians. The same is generally true for equine medicine which appears to be attractive to many undergraduates. We should not make general practice even less attractive to new graduates by excluding it from a "specialty" classification. In summary, post graduate specialization should be encouraged to include small animals, equine, dairy, beef, swine and general practice. We should not be content to leave the requirements for membership as a registration fee or a few sporadic continuing education courses. Correspondence courses coupled with periodic formal lecture presentations would seem to be one program that could be initiated. Undergraduate Specialization It is interesting that specialization should be the topic picked by undergraduates for discussion at Probe '75. I sense that many students feel that species specialization should be encouraged at the undergraduate level. Students in as early as the second year of the professional program have indicated to me that "they are having difficulty knowing which direction to go, large or small animals". This feeling is not surprising since many students have legitimate species interest before entering the Ontario Veterinary College. Students from an urban background are unlikely to be excited about bovine or porcine medicine and surgery. A number of individuals enter veterinary medicine primarily because 'they like horses". These feelings are further reinforced due to the fact that all of the veterinarians on faculty are either species or discipline specialists. In spite of this trend, I strongly feel that specialization at the undergraduate level should not be encouraged for the following reasons: 1) The primary role of the university should be to educate veterinarians, not practitioners. Practice is only one of a number of vocations open to a graduate. Traditionally O.V.C. has been one of the world's great veterinary institutions. It is a credit to the administrators, faculty and previous students that this is true. One of the strongest points of O.V.C. has been the excellent all round quality of its graduates with respect to the various species. A degree from O.V.C. has been a virtual licence to obtain employment almost anywhere and in any field. Other institutions may have stronger equine, bovine or small animal graduates but few rank with O.V.C. in the multiple species approach and the all round excellence of
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graduates. I believe it would be a mistake to compromise this approach. 2) Students should not assume that species interests or preferences before or during their undergraduate program will necessarily be sustained throughout their professional careers. An informal study in 1970 indicated that something approaching 30 to 40% of graduates do not remain in their first position even after the first year. Many obviously remain in a species specialty but a significant number either change species entirely or leave practice altogether and join pharmaceutical companies or federal and provincial government agencies. Many more pursue academic careers in physiology, pathology, anatomy or microbiology. Most nonpractice fields require a multiple species approach. 3) The Ontario Veterinary College now enrolls one hundred and twenty students in each of the four years of the professional program. Nine years ago sixty-five graduates left O.V.C. and the Western College of Veterinary Medicine was not yet conceived. Next year approximately twice that number graduate from O.V.C. alone and enter the profession. In the past, graduates were in the enviable position of choosing one of a number of job opportunities. This is unlikely to continue and soon the shoe may well be on the other foot with a number of graduates competing for one position. No doubt all graduates will find employment but will it necessarily be in the field they initially chose? The student who wishes to be an equine practitioner may well have to choose another field if ten fellow graduates are competing for four or five equine positions. Students should remember that the increased enrolment in O.V.C. did not occur because of an overwhelming need for more small animal or equine clinicians. The impetus for additional graduates was from all sectors of the profession and included the need for more veterinarians in the employment of the federal government and to serve as practitioners in small communities. Undergraduates would only be cheating themselves if they restrict their interests to one or two species. Diversification should be the watchword. 4) General practice is still the most common type of practice in Ontario. I would assume that the same is generally true for Canada as a whole. Most general practitioners who wish to employ a new graduate would obviously desire a clinician competent in all species. A rough survey of placement opportunities in three different issues of the Cana-
dian Veterinary Journal revealed that general practice opportunities outnumbered small animal or exclusive large animal opportunities by almost 2:1. An equal number of opportunities for general practice as for specialty areas was found in a rough count of placements in the Journal of the American Veterinary Medical Association. Many of you will find that after graduation, your professional day to day activities must be balanced with your family responsibilities and your own recreational pursuits. Not everyone with an interest in small animal practice wishes to live in a large city. With the increasing social and economic pressures of large cities, many potential small animal graduates may find that practice in a small community is not only rewarding but the quality of life for your family may be more to your liking. In a word, look to all areas of your life as well as your professional pursuits before choosing the field you want. 5) Students restricting themselves to one or two species fail to realize that no matter what species is chosen, there is a great deal of information that can be gained from the study of other species. To close one's mind to information on any species is regretful and the definite result is a less well rounded and competent individual. 6) If specialization were to come at the undergraduate level, presumably it would be in the form of core subjects plus electives in the final clinical year or semester. A number of arguments may be directed toward even this subtle form of specialization: a) Specialization at this time would be ineffective compared to three to five years after graduation when a veterinarian has allowed all of the information to gel and can see the area in which he is primarily interested. Two weeks of intensive specialized study at the post graduate level would be worth a semester as an undergraduate when the material presented is just more irrelevant information that is not necessarily meaningful. b) The core subjects would necessarily have to be strong enough to allow lateral movement after graduation without further study. Could the present course material be reduced sufficiently to allow time for an elective program? c) With a core + elective program the danger would be that the electives would not necessarily be repeated to allow a student legitimately interested in all species to utilize the information presented in all electives. A student should be able to hear a good small animal elective and a good equine elective offered in the same time slot. It would be
developed and special interest groups have emerged from all facets of veterinary medicine. Administrators of our colleges of veterinary medicine have a tremendous challenge and obligation to see that the quality of individuals entering our profession is maintained. Some critics are charging that because applicants are selected on grades alone, the wellrounded professional veterinarian has alreadv been supplanted by the coolly detached scientist." We should continue to graduate from our institutions well-rounded veterinarians who are capable of choosing any one of many interesting aspects of our profession. Post-graduate specialization from a solid base will result in a better professional individual in whatever area is chosen.
easy to offer each elective only once as occurs at the OVA, CVMA and AVMA annual meetings. d) If students were to take different electives and would therefore not receive the same course should there be the same D.V.M. degree awarded at the end? Are we headed for a D.V.M. with an asterisk or perhaps a group of degrees suitable for each specialty? 7) The argument for specialization at the undergraduate level is that it is needed to allow the vast amount of scientific data available on a species to be offered to the student. However, are we becoming too intent on cramming more information into the student and not really looking at the all round professional individual? Dr. John Herrick (2) in an article on maintaining a standard of excellence in veterinary schools stated: "With Sputnik and a new scientific era, came specialization in all the professions. In the healing professions, the art, the bedside manner, the understanding and the compassion were too often forgotten. The patient was reduced to only a number, and the would-be professional individual became a highly-trained scientific technician. Despite all attempts to circumvent this trend, veterinary medicine, too, has been succumbing to the tenor of the times. Specialty boards have
1. Funk and Wagnalls Standard Dictionary of the English Language. International Edition, New York: Funk and Wagnalls. 1973. 2. HERRICIC, JOHN B. On maintaining a standard of excellence. Vet. Med. small Anim. Clin. 69: 952-954. 1974. 3. RADOSTITS, 0. M. Specialization in large animal practice. Can. Vet. J. 15: 339-344. 1974.
SPECIALIZATION - WHEN, WHERE, HOW J. M. Walker* As VETERINARIANS we are faced with an identity problem. On the one hand, by the nature of our backgrounds and our training, we are interested in the medical and surgical problems of domestic animals which requires a broad education emphasizing basic principles of animal medicine while on the other hand and for various reasons, we are compelled more and more to narrow our field of interest and move closer and closer to the term specialist onto which the description veterinarian will be tacked. It is not my purpose to argue either for or against specialization; I leave that to Dr. O'Dea and Dr. Doig. However, from my posi'551 Riverdale Avenue, #15, Ottawa, Ontario KIS 1S3
tion as a small animal practitioner, I am well aware of the pressures that have a strong influence on the trend toward specialization. There is a natural instinct to advance in whatever one does - let's call it satisfying one's ego - and regardless of what one's profession is, advancement in today's world means specialization. That along with a growing public demand for a high level of diagnostic and surgical competence are important forces influencing a trend to specialization. There is no doubt that an ever increasing number of specially trained individuals in private practice will have a strong positive influence on the standards of veterinary medicine. Achieving higher standards will have a profound effect on the image of the veterinary profession as well as enabling the profession to better meet its obligations to the public it serves.