Published in Veterinary Practice News, Volume 34/Number 9
By Susan Miller, DVM
Sweet little Stitch arrived at Mission Animal Hospital not long ago in rough shape—as did his humans, both adults and children, who walked into our clinic visibly distraught about the suffering of the kitten in their arms. Like all the pets Mission treats, Stitch is a vital member of the family, a playful companion, a soothing cuddle mate, and for his primary owner, Allyssa, a therapy pet who helps her cope with chronic pain.
So when hours earlier they noticed Stitch crying while urinating and licking himself in distress, the family rushed him to a local emergency care clinic. There, instead of help, the family faced a new trauma: the diagnosis of a potentially life-threatening urinary tract obstruction. They had two options: either a treatment plan upward of $6,000, which they could not afford—or euthanasia. Luckily, the ER doctor knew about Mission Animal Hospital and sent Stitch our way—a different way.
A different model requires a different mindset
At Mission, “either/or” is not in our vocabulary—but not because we happen to be a full-service, nonprofit hospital. Our ability to help our clients stems not from our business model, but from our mindset. True, as a non-profit founded in 2015 aimed at providing affordable pet healthcare to families in need, we do see high volumes of patients like Stitch—more than 20,000 last year and the number keeps growing—for whom healthcare cost is the determinative factor. In fundamental ways, though, our clinic is the same as yours: no one wants to turn animals away.
In our clinic, as in yours, the oath to do no harm motivates every single team member. It is the vet who sits across from a frightened family with a pet suffering from a bone fracture, a dystocia, diabetes; the technician who tells a sobbing pet owner her clinic cannot help; the assistant who is berated by a distraught owner for not doing more; and the client-service professional who makes call after call but cannot find another clinic to provide care.
This is us. This is you. We all lose sleep when we cannot help. We all toss and turn wondering what we could have done differently. At Mission we started by thinking differently. Although we offer the gold standard of care most every veterinary school teaches and most every other clinic offers, we see it as merely option A on a spectrum of potential care choices that also includes options B and C.
We present owners with treatment options based on so-called “spectrum of care” choices, aligned with evidence-based medicine, respect for client finances, a do-no-harm approach, and a commitment to non-judgmental, transparent, and thorough client education.
Our spectrum of care method and mindset means we are able to save more pets from distress, disease, and death, more families from despair—and just as important, more of you from sleepless nights.
What is ‘spectrum of care?’
Most of us learned, through our veterinary education, to equate “gold standard” with the standard of care. In reality, standard of care and the gold standard have very different definitions.
● The definition of standard of care is a diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance.
● The gold standard is a term used to describe a method or procedure that is widely recognized as the best option available.
At Mission, some hundred thousand encounters discussing the standard of care with anguished people holding their own version of Stitch lead us to realize two things: 1) an option a client cannot afford is not the best option, and 2) “lesser” options often provide optimal, affordable outcomes and should be considered.
We actively shift our thinking away from academic definitions equating gold standard with standard of care and instead embrace what we call a spectrum of care mindset, which provides a continuum of treatment options. Spectrum of care means offering the gold standard approach as option A, but also offering an option B and option C supported by evidence-based medicine, focused on do-no-harm pet quality of life, client expectations of care, and financial, physical, mental, and emotional limitations of clients that may impact diagnostic and treatment options.
Do no harm, make no judgment
An unspoken assumption inherent in the traditional gold standard model is the position the gold standard option is best—best meaning the most intervention, the most technology, the most likely to extend life the longest. By extension is the assumption other options are versions of failure. Experience has led Mission to reject these assumptions. Closely related to the concept of “incremental care” in human medicine, spectrum of care reframes what it means to provide medical care by acknowledging without judgment the validity of a less-is-more choice, and not just because of finances. A variety of family situations and values can lead them to reject the gold standard.
Consider one Mission client who opted to have the back leg of her Bernese mountain dog amputated in order to extend his life after a cancer diagnosis. She spent the next nine months willingly devoting herself to her pet’s every need—but afterward said she would not make the gold standard choice again; seeing her beloved pet so drastically reduced in mobility, activity, and quality of life was not her version of best outcome. Next time she said she will choose plan B or C—options the spectrum of care model offers without “best/lesser than” judgements.
Trouble from state board?
As we teach the spectrum of care approach, we get this question all the time, “Will I get in trouble from my state veterinary board if I offer a spectrum of care?” It is a fair one. Your state veterinary board, when reviewing any complaints, will rely on good medical records, documented client communication, and solid evidence-based medicine, along with good pain management, and a do-no-harm approach. To meet these standards, the spectrum of care model puts a premium on thorough client communication, so, for example, when a client selects option C, the clinic is certain the client has been made aware of any limitations inherent in the treatment plan selected.
This means doctors must spend additional time with the client, and clinics must provide additional training time for doctors unaccustomed to this practice. Documenting this education in the medical notes and discharge instructions offers the veterinarian solid ground to stand on if ever challenged.
Why it matters
We know now, more than ever, pet owners face myriad obstacles that get in the way of seeing a veterinarian. This is bad for them, and bad for us. While we cannot snap our fingers and solve doctor and staff shortages, we can shift our thinking and make veterinary care more accessible by practicing spectrum of care medicine.
Mission advocates for reframing the “either/or” gold standard paradigm, which limits a veterinarian’s ability to treat patients in the real world, to a spectrum of care model, which expands a vet’s ability to treat patients in the real world. Again, the spectrum should always include the gold standard as option A, but also it will include options B and C.
By shifting the professional veterinary mindset to a spectrum of care model as opposed to a gold standard all-or-nothing, veterinarians can promote a larger and more diverse client base, expand accessibility, and positively impact pet and human health; the shift is also good for business. By identifying this strategy, naming it, and most importantly, educating on it in veterinary school, we not only help prepare the next generation of veterinarians for actual practice, we also teach them to be inclusive and nonjudgmental.
Stitch gets to go home
“I thought I was going to lose him, and my heart was breaking.” Mission’s spectrum of care allowed us to change the outcome for Allyssa. We offered options A, B, and C for Stitch. Allyssa knew the risks and made informed decisions that were best for her family. She chose to have Mission remove the urinary blockage using our limited hospitalization protocol, and Stitch was back home in a matter of days, on his way to a full recovery.
Today, Allyssa and her family are far better educated about managing Stitch’s stress. Allyssa feels confident and in control knowing she has a place to go where she will always be offered choices she can assess given the needs and desires of her family.
No one can promise a happy ending every time; no one can avoid heartbreak every time. But spectrum of care medicine allows us to be our best by partnering with our clients as we work toward a common goal: the best possible care for their cherished family members.
Susan Miller, DVM, is a University of Minnesota College of Veterinary Medicine graduate. She purchased Mission Animal Hospital in 2014 and converted the business organization into a nonprofit. Before purchasing Mission, Dr. Miller worked in private practice and was profoundly impacting by the number of families struggling to care for their pets. She believes in offering Spectrum of care medicine to help pet owners make educated decisions about veterinary care. Dr. Miller also volunteers with Worldvets, helping with surgical clinics in countries with limited veterinary care.