DECISION AND SECTION 43 STATEMENT TO THE VETERINARY COUNCIL BY THE COMPLAINTS ASSESSMENT COMMITTEE: CAC15-07 Dr A (Section 39 referral/complaint) Dr A B Dr C Veterinarian Clinic where Dr A works Former staff member at B, who raised the concerns about Dr A Names and locations have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person s actual name. Summary 1. A Complaints Assessment Committee (CAC) of the Veterinary Council of New Zealand (VCNZ) has investigated the above referral. Under section 43 of the Veterinarians Act 2005 (the Act), the CAC has reached a decision as set out below. Background 2. Dr A is a senior veterinarian at B. 3. This decision statement follows the investigation of matters raised by a former employee of B, Dr C, veterinarian, which were referred to the CAC by Council. 4. Dr C raised concerns about various aspects of Dr A s current practice and her belief that lack of continuing education means that his treatment methods and advice are out of date. Information considered 5. The CAC considered the following information. The original letter of concern from Dr C (6 February 2015). A letter of referral from Council s Notification Review Group (13 April 2015). Dr A s response received 3 May 2015. Dr C s comments of 8 June 2015 on Dr A s response. Clinical records for cases specified by the CAC. Random clinical records as requested by the CAC. Brief case summary 6. Dr C worked as a locum at B from May 2014 to November 2014. 7. In a letter dated 6 February 2015, Dr C advised Council of her concerns. This was considered by Council s Notification Review Group who referred the matter, under its delegated s39 authority, to a CAC to investigate under s40 of the Act. Issues raised in the complaint
2 8. Dr C advised concerns about Dr A s usual practice in relation to anaesthesia of animals. As well as this, she questioned his decision making, use of pain relief, record keeping and engagement in continuing education. 9. According to Dr C, Dr A s standard protocol for anaesthesia in dogs is xylazine pre-med followed by thiopentone induction. She reported that cats receive a single injection of xylazine/ketamine (cat speys and some other procedures are not intubated). The recoveries are extremely long. This protocol also applies to all patients regardless of age and health status. Dr C reported that: she believed that the drug dosages are not very weight specific drug dosages given to patients are not recorded anywhere she had raised her concerns with Dr A and that he had told her that he used this protocol as he was uncomfortable using newer protocols as he was not familiar with them. Dr C cited several specific cases to demonstrate what she believed to be the inadequacies of the anaesthesia protocol. She also raised concerns about apparent failure to keep animals warm during anaesthesia. She noted that the clinic is very cold and draughty in the winter yet no blankets, heat pads or other heating devices are used on patients during or after anaesthesia. 10. Dr C wrote that no pain relief is given pre or post-op to any surgical patients, with the exception of oral NSAIDS sent home for orthopaedic surgeries and that, in these instances owners were not instructed to give the medication until the following day. According to Dr C when questioned about this, Dr A explained that he doesn t give postop pain relief because it makes the animals too sleepy and he believes that xylazine is an adequate pain reliever. 11. In terms of record-keeping, Dr C wrote that computer records often have no age and/or weight recorded for patients and medication (especially repeats) were often dispensed by handwriting the instructions on the dispense packaging but making no note whatsoever of any of this on the computer records. 12. Dr C noted that she has concerns about what she believed to be a lack of continuing education for Dr A. She considered treatment methods employed and advice given to be out of date and that there is generally a lack of diagnostic investigations offered as well as a lack of advice given to clients regarding preventative/maintenance care. In her view, the areas of dentistry and dermatology are particular areas requiring further education. 13. Dr C advised that she had raised her concerns with Dr A on several occasions and had offered to help make changes. However, she wrote I could see that there was no way I would achieve anything while only working 1-2 days per week. I left the practice because the standards did not align with mine and I was distressed seeing animals going through pain post-op. 14. In response, Dr A addressed each of the concerns raised by Dr C. He advised that, regarding anaesthesia drugs, there are many anaesthetics/ analgesics/sedatives available including Acepromazine, Buprenorphine, Xylazine, Medetomidine, Butorphanol, Diazepam, Pethidine, Ketamine, Thiopentone, Propofol and Isoflurane and that vets normally pick and choose drugs based on their preference and length of the procedure etc. In relation to the matter of temperature, he wrote that we have two air conditioners (could be used as heat pumps or air coolers);one fireplace (which we use every winter);
3 two oil column heaters; 4 electric blankets; 3 hot water bottles and a couple of wheat bags. He also reported the use of electric blankets or a Bair Hugger in longer procedures or while operating on rabbits. 15. Dr A noted the sedative, muscle relaxant and analgesic properites of xylazine as reasons that other forms of pain relief had not been used for routine desexings. He reports that Temgesic or Butorphanol had been used selectively in the past for routine desexings only if we considered that the patient needs it. Dr A reported that recently (for the past few months) staff at the clinic have been using Buprenorphine for post-operative pain relief for all the routine procedures including desexings. He wrote we use Buprenorphine, NSAIDS, Codeine and Tramadol as pain relief based on the type of procedure and noted we have always used Buprenorphine for lots of soft tissue surgeries or orthopaedic surgeries followed by NSAIDs. 16. In response to Dr C s concerns about record keeping, Dr A wrote about the difficulties that exist sometimes in obtaining all patient details. He advised that he has spoken to staff to be more vigilant about entering complete animal details. Regarding his own notes, he wrote I write my records properly including history, clinical findings, differentials and treatment given. He acknowledged that sometimes routine desexing records are written briefly and also that abbreviations are sometimes used in medical records. 17. As evidence of his continuing medical education, Dr A listed five workshops or conferences (including one international) that he has attended in the last 4-5 years. He wrote that, at clinic level, we discuss almost all the cases with each other. He advised that he will be looking at attending seminars related to veterinary anaesthesia or analgesia in future. 18. Regarding Dr C s claims that there is a lack of diagnostic work, Dr A wrote that: we always offer further diagnostic work up but it s up to the clients if they wish to go ahead or not we routinely send ear swabs for culture sensitivity tests in chronic recurring ear infections but no every client says yes for it. 19. The CAC requested and received copies of the clinical records for the cases referred to in Dr C s notification as well as the clinical records for a selection of random cases seen by Dr A. The Code of Professional Conduct for Veterinarians (the Code) 20. The CAC referred to the requirements of the Code of Professional Conduct for Veterinarians (the Code). The following sections of the Veterinary Services section of the Code is relevant to this complaint: Section 1 Veterinarians must keep their skills and knowledge up to date by taking part in relevant continuing professional development activities that maintain and develop their competence and performance. Explanatory notes b. The public has the right to expect that veterinary services are provided in a competent and contemporary manner and that veterinarians will maintain and enhance their professional skills and knowledge.
4 c. Clinical standards change over time. Methods of treatment which may be considered acceptable at one time may not be considered acceptable at a later date. Clients have the right to expect that veterinarians will keep their knowledge in their field of practice up to date. d. Veterinarians must comply with VCNZ's requirements for continuing professional development. Section 3 All veterinarians must take reasonable care to ensure that the practice that they are working in is operated to the standard expected in this Code. Explanatory notes e. Veterinarians who believe that premises, equipment or other resources/systems in a practice are below the standard expected should raise those concerns with the practice owners or principals. Where such concerns are not appropriately resolved they should be brought to the attention of VCNZ. Section 4 Veterinarians must maintain clear and accurate clinical records. The records must: a. Be of such detail that another veterinarian could take over the management of the case at any time. Explanatory notes f. Veterinarians have an obligation to maintain medical records which contain enough information to allow another veterinarian to easily take over the case. The medical history should be able to be organised and retrieved efficiently, and documented in a legible form. The medical record facilitates communication between veterinarians providing treatment. g. Records should contain relevant clinical history and findings, decisions made, treatments provided and information provided to clients. The record should document relevant communication between veterinarian and client that directly relates to the patient. 21. The CAC also referred to the Competency Standards and Performance Indicators for Veterinarians (the Competency Standards), including: 5. Implement safe and effective veterinary procedures and therapeutic strategies Indicators: Safely induces, maintains and monitors analgesia and anaesthesia and takes steps to ensure safe and humane recovery Carries out surgical procedures using appropriate techniques and procedures before, during and after surgery that minimise the risk to the animal and maximise the likelihood of a successful outcome CAC considerations 22. Anaesthesia and patient warming While the anaesthetic drugs being routinely used by Dr A, as cited by Dr C, were first used many years ago this alone does not make their use today inappropriate. Likewise, if something has always been done a certain way, that in itself is not a reason to continue to do it that way e.g. if new anaesthetic drugs and techniques are more appropriate. The
5 CAC notes that Dr A reported that there had only been rare complications but no fatality associated with the anaesthesia at B. With regard to patient warming Dr A advised that B has a variety of methods available to maintain patient temperatures during surgery and hospitalisation. (This was confirmed by a senior colleague at the practice.) There are however differences in opinion between Drs C and A about how frequently and effectively these methods are used. 23. Pain Relief Peri-operative pain control has moved a long way in the past decade(s). What was acceptable to the veterinary profession, and the public, prior to these developments is no longer acceptable to either party now. The public expects that pets will not experience any discomfort if treatments are available to alleviate this discomfort. In his response Dr A has reported that there have been changes in the clinic s use of post-operative pain relief drugs with additional pain relief now being given. 24. Continuing Education Dr A lists many sources of continuing education in his response that would appear to more than adequately meet the requirements of the Code. He has also undertaken to target attending seminars related to veterinary anesthesia or analgesia in future. 25. Record Keeping The recent clinical records for consultations provided by Dr A meet the requirements of Section 4 of the Veterinary Services principle of the Code (listed in 20 above). The two surgical records for August and September 2014 that were specifically requested by the CAC are also adequate to meet the requirements but could be improved by the inclusion of more detail. It would be appropriate to include notes relating to the pre-surgical assessment of the animal, the name and dose rates for the drugs given, the length of the anaesthetic, as well as the post-operative instructions given. Dr A reports that the issue of maintaining more detailed notes has been raised in a staff meeting. 26. Diagnostic Workup Dr A responds in the section regarding Feline Lower Urinary Tract Disease (FLUTD) that We always offer further diagnostic work up but it is up to the clients if they wish to go ahead or not. Clients decide based on their financial situation. The CAC agrees that it is up to the client to decide what level of diagnostic workup they are happy with. Ideally all clients should be offered best treatment options at every consultation and the veterinarian should not tailor the options offered based on the socioeconomics of an area or their previous experience with that client. The assumption that a client will not accept the best treatment option, and because of this not offering it, is providing a disservice to those clients who want and can afford the best treatment for their pets. Equally it is not the veterinarian s role to force clients to undertake workups that they neither want nor can afford as long as animal welfare requirements are met. The treatment options offered and the client s acceptance or refusal of the options should be recorded in the clinical history. 27. General The CAC thanks Dr C for raising her concerns. Her action was consistent with Section 3 of the Veterinary Services principle of the Code (listed in 20 above).
6 The New Zealand veterinary profession is committed to a culture of continuous improvement. Sharing of experience and best practice, both within and between veterinary practices, through collegial discussion is to be encouraged as it is a major contributor to maintaining and improving standards. CAC recommendations and suggestions 28. The CAC recommends that Dr A target some of his continuing education to the areas of anaesthesia, pain relief and dermatology but not at the exclusion of other topics relevant to his area of practice. It would be appropriate for Dr A to discuss with companion animal veterinarians, outside of B, how they are managing their patients review the Code with particular reference to paragraph 4 of the Veterinary Services section on clinical records. Dr A then needs to amend his protocols and practice as needed to ensure that the Codes requirements are met. 29. The CAC suggests that Dr A regularly re-evaluate all clinic protocols, in light of current knowledge and recommendations by appropriate veterinary advisory groups. While this may not result in changes to these, the practice needs to be able to show that they regularly review these and can demonstrate that these are informed by the current scientific evidence. The CAC suggests that the first protocols to be re-evaluated be those concerned with anaesthesia, pain relief and patient warming. Decision 30. The CAC considers that this case can be closed and no further action 1 needs to be taken. Reasons 31. The reasons for the CAC s decision are: further education in anaesthesia, analgesia and dermatology will ensure that Dr A is aware of recent developments and current practices in these areas regular reviews of clinic protocols, in the light of current knowledge and recommendations by appropriate veterinary advisory groups will help B comply with the Code s requirements Dr A has demonstrated insight by reviewing the use of pain relief and record keeping protocols in recent months Dr C s stated intention (in raising the concerns) was not to judge or criticise but rather to suggest more effective and modern methods of veterinary practice as a means of helping both the clinic, the clients and the animals. Dr C stated I do not seek any legal or formal action to be taken against [the] veterinarian. Dr Mark Simpson Chair - Complaints Assessment Committee 14 September 2015 Date 1 Pursuant to s43(1)(f) of the Act.