Breaking down the barriers to accessible veterinary care

Providing accessible veterinary care can feel like an internal tug of war. On the one hand, access to care represents the humane, empathic, relationship-centered and ethical aspiration that we collectively seek to embrace as a healthcare profession. On the other hand, access to care challenges can be thorny, and we struggle at times to find the ‘right’ way to move forward with case management and the ‘right’ way to advocate for patient care.

We do not always have access to or knowledge of the breadth and depth of resources that help us get from point A to point B. We may feel barricaded by obstacles that seem bigger than us, out of reach or otherwise beyond our control. In addition, we may feel torn between how we were instructed to practice medicine during our formative years in veterinary college and the realities of clinical practice.

That tug-of-war feeling persists because there is uncertainty about how to proceed. What are ‘best practices’ and should we even refer to them as such, because ‘best’ implies that other avenues are ‘lesser’? Rather than crafting binary language around access to care, let us shift the focus onto the core of the issue. We begin addressing barriers through the recognition that, to serve the patients who need us, care must be contextual and provided along a continuum of acceptable options.

The Journal of Feline Medicine and Surgery’s ‘Accessible veterinary care’ special collection initiates an important conversation about this vitally important subject, across a range of subjects.

Several papers in the collection acknowledge the cats that are largely excluded from care: free-ranging, unowned (community) cats. Dr Ma and colleagues report on the characteristics of cat semi-owners. ¹ These are individuals who take care of community cats, yet do not consider themselves to be owners. Engaging with semi-owners on their own terms can help improve cat welfare and advance population control.

Currently, the most effective tool for feline population control is spay–neuter surgery. Despite some debate, there can be little doubt that spay–neuter has played a critical role in decreasing shelter intakes and euthanasia. Dr Bushby challenges and invites private practitioners to learn and implement high-quality, high-volume techniques. ² This will empower veterinarians to provide more surgeries at a lower cost. For those concerned about the safety of high-volume approaches, the review highlights the high-quality aspect by pointing out that mortality and complications are much lower in high-volume settings than conventional ones.

Dr Neal and Dr Greenberg’s interesting approach to policy alternatives reminds us that ‘cats historically receive veterinary care at approximately half the frequency as dogs’. ³ One reason is the stress of veterinary visits. Access to telemedicine is therefore particularly critical for cats. This could be greatly expanded by the ability to establish a full veterinary–client–patient relationship virtually. The article formally analyzes regulations in human medicine for potential application to veterinary medicine. One striking fact that emerges is that all 50 states in the USA allow virtual establishment of a physician–patient relationship!

There has been a greater awareness of caregiver burden recently. This is particularly important for cats, as they can be difficult to medicate and are often highly stressed at veterinary visits. Dr Spitznagel and colleagues provide the first analysis focusing on caregiver burden specifically for cats. ⁴ Caregiver burden for ill cats was lower than for ill dogs, but the difference was not considered clinically significant. The difference might be because cats do not routinely receive veterinary care, even for chronic conditions. The study confirms that caregiver burden can be high for sick cats and tabulates the burden and frequency for different conditions. This work could help make care more accessible by decreasing the burden for common, high-burden conditions such as kidney disease.

Approaches that depart from established norms are important ways to reduce caregiver burden and expand access to care. Dr Gottlieb and colleagues describe a lower intensity, home-monitoring protocol for feline diabetes. ⁵ The protocol reduces the costs and number of veterinary visits, and success rates and owner acceptance were favorable. A previous study reported that up to 10% of owners elect euthanasia when cats are diagnosed with diabetes; no caregivers in the retrospective study by Gottlieb et al chose this option.

Advanced veterinary care frequently involves surgical procedures, which have high up-front costs, particularly in specialist facilities. Dr Hohenhaus describes a program at a tertiary veterinary teaching hospital that provides access to advanced care for cats and dogs in rescue settings. ⁶ The report lists the types of procedures most commonly required in this population, as well as the enormous need for advanced care among rescued cats and dogs. This care is often beyond the reach of rescue groups. This program improves welfare, reduces moral distress for veterinarians, provides teaching opportunities for interns and residents, and provides a model for other organizations.

In my view (LJ), the two-part spectrum of care review by Dr Englar is the jewel in the crown of the special collection. To quote Dr Englar, in part I: ‘When care is not framed as all-or-none, either/or, best versus lesser, the provider and client can agree to diagnostic and/or treatment plans that individualize the practice of veterinary medicine. Care is tailored to the patient along a continuum of acceptable options.’ ⁷ Part II details the critical communication skills required to effectively provide spectrum of care medicine. ⁸ Once again, Dr Englar says it best: ‘As veterinarians, we bring knowledge into the consultation room about animal behavior and welfare, health and wellbeing, illness and disease progression, diagnosis and prognosis. What we do not know when we initiate a veterinarian–client–patient relationship is who we will meet on the other side of the consultation table.’ ⁸ Shared decision-making is central to spectrum-of-care, contextual approaches: ‘The practice of unconditional positive regard suggests that veterinarians accept clients for who they are and meet them where they are, rather than hold them to impossibly high standards.’ ⁸

The advantages of innovative thinking to contextualized care are vast. Contextualizing care broadens the scope of practice by focusing on the range of options that are available to the healthcare team to devise a patient-specific plan. Rather than tying our hands, contextualized care frees them so that we can sift through combinations of options to find what is truly best for the patient and client in the context of their needs, abilities and capacities.

Linda Jacobson Toronto Humane Society, Canada Ryane Englar University of Arizona College of Veterinary Medicine, USA