When What’s Possible Isn’t Doable: The Spectrum of Care Approach

A ‘spectrum of care’ approach helps veterinarians bridge the gap.

Dr. India Lane recalls her days as a veterinary student. “I remember discussing the ‘Cadillac’ approach to a case along with the ‘Buick’ and ‘Chevy’ approaches,” said Dr. Lane, professor and associate dean for academic and student affairs at the University of Tennessee College of Veterinary Medicine in Knoxville. “The vehicle models were used as metaphors for economics-based choices – i.e., what the client can afford.”

Today’s graduates might not think in terms of Buicks or Chevys. They are more apt to speak of “spectrum of care” or “incremental care” to describe treatment options that might out of necessity fall short of the gold standard of care, whether it’s for lack of affordability, the severity of a pet’s illness, or a client’s inability to adhere to a strict care regimen. What’s more, today’s graduates are learning that speaking directly – but with compassion – with their clients can reduce the stigma for the veterinarian and client as they settle on a care plan that some may consider “second best” or “good enough.”

Care ‘creep’

“The standard of care ‘creep’ is not intentional,” write the authors of the 2018 report “Access to Veterinary Care: Barriers, Current Practices and Public Policy” by the Access to Veterinary Care Coalition. Rather, society has come to expect the gold standard of care because the technology is available, practitioners face an increased risk of liability, and income-producing technology can help practice owners maintain a comprehensive medical facility.

But the rising bar for “standard of care” comes with ethical and practical challenges.

“A veterinary care system that does not recognize the need for a middle-ground approach to case management with a sense of appreciation of socioeconomics, the animal’s welfare and the impact of the human-animal bond connection is in violation of Tannenbaum’s first fundamental approach to our role as veterinarians,” according to the report’s authors. [Jerrold Tannenbaum is an expert and author on animal ethics and welfare.] “Providing some level of care while considering the situation’s financial and empathetic realities would seem to be a logical, moral and ethical approach.”

In 2021, the American Association of Veterinary Medical Colleges established the Spectrum of Care Initiative (SOCI) with support from The Stanton Foundation. According to AAVMC, SOCI is intended to provide “the infrastructure, guidance, and assistance for an inclusive and collaborative approach to supporting and enhancing [spectrum-of-care] training in veterinary education.”

“Spectrum of care is an important strategy for increasing the accessibility of veterinary care by providing care options that are responsive to clients’ circumstances, including (but not limited to) financial limitations,” said Dr. Julie Noyes, executive director of the Spectrum of Care Initiative. “Other client factors that veterinarians need to be prepared to consider are clients’ beliefs, values, expectations, and relationships with the patient. By providing healthcare for more patients and building positive, loyal relationships with clients, spectrum of care practice can contribute to veterinarian and societal well-being.”

Michael J. Blackwell, DVM, MPH, director of the Program for Pet Health Equity, a unit of the Center for Behavioral Health Research at the University of Tennessee, said, “Historically, veterinarians have had to engage in incremental patient management for a variety of reasons, not the least of which are limitations in what the patient’s family is able or willing to pay. What has changed over the past five years is more open discussions about the importance of [incremental care] to avoid nontreatment or euthanasia. The discussions have highlighted the lack of standardization in treatment protocols. We can expect numerous patient management protocols to be developed, documented, and taught.”

Preparing tomorrow’s veterinary professionals

For a spectrum-of-care approach to be successful, veterinarians must feel confident in discussing the advantages and disadvantages of various treatment options, write the authors of a 2021 Journal of the American Veterinary Medical Association article, “Spectrum of Care: More than Treatment Options.” And in veterinary medicine – as in human medicine – the doctor’s recommendation can be the biggest influence when people are deciding among treatment options. “Therefore, how care options are presented can be as important as which care options are presented,” write the authors.

Students at the Frank Stanton Veterinary Spectrum of Care Clinic at Ohio State University College of Veterinary Medicine are taught just that. Opened in June 2021, the clinic is a key component of the veterinary curriculum, providing hands-on clinical experience for students, according to administrators who shared comments with Veterinary Advantage.

Spectrum of care is intertwined throughout the four-year curriculum. Students in their first three years learn and refine their knowledge, skills and application in a real-world setting. They learn the function and operation of a small-animal general practice as well as the various roles of members of the veterinary healthcare team.

During the final year, students serve as the doctors while the faculty serve as coaches. The faculty spend time in observation rooms adjacent to exam rooms, so they can see and hear the student doctors engage with clients, perform physical exams, and discuss diagnostic and treatment options.

“Students participate in communications courses and training, learning how to effectively communicate with clients in a variety of situations, including having difficult conversations about euthanasia, medical errors and financial limitations,” explain the administrators. “They learn about cultural humility and develop cultural competencies, social and socioeconomic awareness, and how to communicate effectively with a broad array of clients, all of which are critically important to be successful as a veterinarian.

“Through these various sequential experiential and hands-on learning opportunities across the four-year curriculum, students develop competency and confidence in communicating and providing a wide array of care options to meet clients and their pets where they are.”

Said Dr. Noyes, “The AAVMC-SOCI Task Force has made significant progress in developing an evidence-based, outcomes-driven approach for supporting veterinary schools in preparing students for spectrum of care practice.” The Task Force developed an SOC Education Model, which identifies essential abilities for graduates to acquire during veterinary school to provide clients with a wide range of care options that fit their needs while ensuring viability of the practice business, she said.

The Task Force is in the process of gathering spectrum of care case studies, content, assessments and learning experiences with the vision of creating a centralized library that programs can access to address gaps identified during the curriculum mapping process, said Dr. Noyes. They are also creating recommendations for change management strategies to aid programs in implementing curricular changes required to support the SOC Education Model.

AAVMC has established the SOCI Advisory Community to broaden the scope of perspectives beyond those in academia, she continues. The advisory community includes practitioners, practice owners, business experts, and representatives from veterinary associations and practice groups. “This community provides a platform for workforce perspectives to share input on how to educate veterinary graduates to enhance animal health through spectrum of care practice.”

Said Dr. Lane, who is a member of the SOCI Task Force, “Veterinary students may find themselves immersed in ‘state of the art’ care for a good portion of their clinical placements. Students and practitioners may worry about legal or ethical consequences for providing care that is not the latest and greatest option. Even without consequences, managing client decisions across a variety of treatment options can increase moral distress if a veterinarian thinks they have failed to convince a client to pursue the ‘best’ treatment option.

Key questions

Although veterinarians may choose different parameters when dealing with a client with significant financial limitations, the following are suggested to be used for objective patient evaluation, according to the Program for Pet Health Equity:

• Do I have the skills/resources/equipment to adequately and humanely treat and manage the case?
• Is there a good prognosis? Is it treatable? Is it manageable? Are there multiple problems?
• If it isn’t treatable or manageable, is there a simple palliative option that can extend and provide good quality of life?
• Is the problem an ongoing or chronic condition?
• Can the owner afford follow-up care or management?
• Can the owner provide overnight monitoring at an emergency clinic if it is necessary?
• Is this animal in critical condition?
• Would significant amounts of money make a difference in a positive outcome?

Source: Program for Pet Health Equity, Center for Behavioral Health Research, University of Tennessee, pphe.utk.edu/resources/incremental-veterinary-care

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