See the Full Issue
November 2023
Moving Toward Truly Collaborative Care
This Central Line podcast episode with Elizabeth Maxwell, DVM, MS, DACVS- SA, CVPP, and Candice Manganaro, DVM, explores collaboration among general practitioners, specialists, and emergency veterinary care teams.
A Conversation with Elizabeth Maxwell, DVM, MS, DACVS (Small Animal), CVPP, and Candice Manganaro, DVM
Collaboration among general practitioners, specialists, and emergency veterinary care teams is sometimes bumpy. What gets in the way? For those considering asking for a consult, it can create an anxiety-raising back-and-forth of “should I or shouldn’t I reach out to a specialist”—especially if these interactions haven’t been pleasant in the past. For specialists, the biggest obstacle is often how to carve out the time. We can all relate to the feeling of that unscheduled call or “ping” of an email when our schedule is already packed.
But for those who put in the work to create good relationships, the person on the other end of the line (or the text or the email) can become a vital resource and help save energy and money on diagnostics, medications, and unnecessary steps—not to mention improving patient care.
That’s where the Collaborative Care Coalition (CCC) comes in. It’s a nonprofit made up of general practitioners, specialists, academics, and industry partners who are dissecting the idea of collaboration and working to overcome barriers based on old habits or due to a lack of experience flexing that collaborative muscle.
CCC has research to back up the idea that, far from being “just a soft skill,” the ability to collaborate leads to better patient outcomes. Working together may seem like a trivial thing that we’re supposed to know how to do naturally, but the so-called softer sciences are often the hardest to get right.
Central Line: The AAHA Podcast sat down with Elizabeth Maxwell, DVM, MS, DACVS (Small Animal), CVPP, who is on CCC’s board and is a surgical oncology specialist, and Candice Manganaro, DVM, who have been collaborating with each other for nearly a decade.
When asked what she would put a on sticky note that would appear on every veterinary professional’s mirror to see first thing in the morning, Maxwell said the quote she has on her desktop computer at work is, “A smooth sea never made a skilled sailor.”
And that may be a good way to think about the hard work of learning to collaborate.
Note: Content has been edited for length and clarity.
Katie Berlin: The idea of collaboration between general practitioners and specialists and emergency veterinary care teams is sometimes a little bit fraught. And it’s nice to think about us all as being on the same team. Can you give us a rundown of what the coalition is?
Elizabeth Maxwell: The Collaborative Care Coalition, [which] we also refer to as the CCC, is a volunteer-based nonprofit organization that’s comprised of primary care veterinarians, specialists, individuals from academia, and industry partners. And the mission of the CCC is essentially to achieve optimal health care for animals, [an] advanced veterinary profession, and [to] evolve the relationship between primary care veterinarians and specialists.
“We have to want to build those relationships, because if we don’t put that as a priority, then it’s never going to happen.”
—Elizabeth Maxwell, DVM, MS, DACVS (Small Animal), CVPP
One of the main areas of focus for the CCC is research. Veterinarians always are about evidence-based medicine, so a lot of our focus is on research that shows that collaboration improves outcomes.
Communication and Relationship Building
KB: We do develop a relationship, for better for worse, with the specialists that we refer to. And I can recall so many phone calls and interactions that I’ve had with specialists over the years—really good ones; you know, ones where I felt like we really had a rapport—and ones that really weren’t that way at all. And I always felt like kind of a thorn in their side. I don’t know how much of that was my own perception and how much of it was actually the way that they were approaching me. But I do feel like that’s not an uncommon feeling among our colleagues.
Dr. Maxwell, how do you feel about that? What is the roadblock there?
EM: I think sometimes very simply it’s time, right? Communication is the biggest thing. And with everyone being overworked and burned out, you know, to take the time and get on the phone to talk to someone about a case, sometimes it’s just not there.
And when specialists are just sending records from appointments to their primary vet, there’s no relationship building at that point. So the relationship sort of has to be established at the beginning; for the first few cases, you’re calling, you’re having that communication, and then maybe emails, and then the paperwork can kind of continue that more informal relationship.
We have to be intentional about the time. We have to want to build those relationships because if we don’t put that as a priority, then it’s never going to happen.
KB: And that parallels how we are with clients, right? If you don’t take the time to build those relationships, you’re not going to reap the benefits of that relationship later on down the road. Eventually, it will save you time to have that kind of relationship with your clients.
Dr. Manganaro, how do you think that collaborative care can actually help us deal with the overload that we’re all facing?
Candice Manganaro: That was part of what I was thinking about, too. I want my clients to know every single option. In Dr. Maxwell’s case, we’re talking about oncological cases. And so I always try to get my owners to at least have a consult. Right now, a consult might be months out, and if that owner is not going to do that, then I don’t want to take up that slot for somebody else that could have gotten in.
So I will usually send an email like, “Here’s the case summary. Let me know when you can, if you want to email me back, or you want to call me, whatever works.” But, that way, I can get a little bit of, “This is what we would potentially expect. This is the rough idea of what we might be talking about.” And then I can communicate that to the owners.
Right now, that’s harder because of the time, but it’s also more important because of the lack of time. It’s about finding the time to communicate that between me and the specialist, and the owner, so that everybody’s on the same page. And that’s always my goal: For everybody to know everything that’s going on.
How GPs Can Help Specialists
“That’s always my goal: For everybody to know everything that’s going on.”
—Candice Manganaro, DVM
EM: I honestly don’t mind when cases come for the conversation, even if they don’t pursue surgery. I never have that feeling that “Oh, they took up a surgery slot” you know? But what I find really helpful just from the specialty standpoint—because we’re booking out one to three months in advance—it’s often really helpful when the primary vet calls us and they say, “Hey, before I refer this case, are there any diagnostics that you want me to do that can help facilitate things on your end?”
CM: And medications, too. “Do I start this?” and “What do you want me to do before he gets to you, so I don’t mess up the opportunity to sample things?”
EM: Sometimes when they come with an ultrasound or they come with radiographs that helps us get one step closer to treatment, if that’s the route that they’re going to take. So I find it to be really helpful when the vets call me and they say, “What blood tests can I do? What do you need?” And if they’re able to do it, then that’s really, really helpful on our end, and for the patient, because then they’ve already had the workup and they can come in for treatment, you know?
CM: And sometimes the answer is “We don’t need that” or “We’re going to repeat that” so I haven’t spent extra time and money on something that’s going to be repeated, or not needed, for that particular case.
Teachable Moments
EM: A lot of primary vets say, “Well, I’m not going to do this workup because they’re just going to repeat it at the specialty hospital.”
But I don’t feel like that’s necessarily the case if we have the information that we need to proceed with treatment. And I think some of that [is a] breakdown in communication. For example, for a cruciate ligament tear, you might take radiographs of the knee. But for surgical planning, we need to take specific views.
I know some surgeons that actually go out to their referring veterinarians and say, “This is how you do TPLO rads. This is the marker that you can put in it so that we can do the measurements at our practice.” So having that relationship and saying, “This is how we need it done so we don’t have to repeat it,” is really helpful because, without that communication, you’re going to take radiographs your way and then they’re going to have to repeat it.
We don’t want to repeat diagnostics. We’re not trying to just make more money on the patient. We just need to do what we need to do to treat them. And I think that’s a misunderstanding, honestly, from both sides.
“We don’t want to repeat diagnostics. We’re not trying to just make more money on the patient. We just need to do what we need to do to treat them. And I think that’s a misunderstanding, honestly, from both sides.”
—Elizabeth Maxwell, DVM, MS, DACVS (Small Animal), CVPP
KB: I think we really suffer from pride when it comes to these cases. We worry so much about how we’re going to be perceived. And I’m sure specialists also don’t want to tell us that you don’t know or that you couldn’t fix something. How do we take the ego out of these conversations? It just seems like no matter whether we want to admit it or not, it’s there.
EM: It’s very easy for us, right? To be self-conscious about the decisions we’re making when someone else is going to be reviewing over it, whether it’s primary or specialty. And you know, there has to be a mutual respect—that’s kind of the bottom line. And it always upsets me when I hear about primary care vets saying that they felt disrespected or mistreated, that a specialist made them feel stupid. I think that from the specialty side, we have to appreciate that long-term relationship that the primary care vet has built with their clients and with their patients.
There are a lot of times that I’ve discussed treatment options with patients that have been referred and they tell me, “Thank you, but we’re going to discuss it over with our primary vet first and then make a decision.” And that always just shows me how strong their bond is with their primary vet, and how they’re going to rely on them for the decisionmaking for their pet’s health care. I’m always very impressed by that.
The Bravery of Reaching Out
EM: I think we all just naturally want to help people and help our patients. And I never feel burdened by a call from a primary care vet asking about a case, whether it comes to me or not. I don’t care about that. I want to help. And most of the other specialists that I’ve talked to also have no problem getting on the phone and helping any veterinarian that needs help.
And I don’t think it happens as much here in academia, but when I worked in private practice, we got calls all the time from the referring veterinarian saying, “Hey, I’m in surgery. This looks weird. What should I do?” I think it’s great because it’s in the best interest of the patient. If you’re in surgery and you feel stumped, you’re probably going to feel bad calling the specialist, like you feel like you’re in over your head and maybe you’re embarrassed, and you don’t need to feel that way. I think that it takes a brave person to get on the phone and say, “I need help. I’m in surgery. I need help.”
“I have a lot of respect for the vets that give me a call and say, ‘Please let me know what I need to do.’”
—Elizabeth Maxwell, DVM, MS, DACVS (Small Animal), CVPP
I have a lot of respect for the vets that give me a call and say, “Please let me know what I need to do.”
A Lifeline for New Grads
KB: As a primary care vet, often we do feel like we have to be good at everything, know how to deal with every situation. And that can be really scary, especially for newer grads, because everything is like the first time.
I’m sure it would be really comforting for a lot of more recent graduates to know that if they don’t have their own boss available to help them, they might be able to call a specialist and say, “Look, I’m stumped. I don’t know what to do next.”
EM: So, the CCC did a study where they were looking at perceptions of the relationships between primary care vets and specialists. They surveyed 242 primary care veterinarians, and they found that 55% felt that they were treated with mutual respect, but 22% felt that the specialist looked down on them for their treatment decisions or for not referring sooner.
So I feel like, from that perception, we can do a lot better on our end to build that relationship because it’s been proven that knowing one another on a personal level will improve the quality of collaboration. We always talk about things that we can do, like lunch-and-learns, roundtable discussions, or continuing education seminars. Those are all really good opportunities for the specialty hospitals to interact with their referring population or their veterinarians around the area to start building those personal relationships.
That allows you to get on the phone and make that call or text someone when you need help with something. I definitely think there’s a lot of areas of growth for practices to make steps toward collaborating better.
Making Collaboration Visible
KB: Say you have a patient whose owners are reluctant about going to the specialist. They’ll go if they absolutely have to, but they’re not really sure if they want to or if it’s worth it. What does that interaction look like to you?
CM: I do lay out “This is what a specialist gets us.” And those are sometimes the cases where I tell the owners, “This is what I think, but let me check really quick.” And I’ll call Dr. Maxwell and say, “Hey, this is what I think. What else can I tell these guys?”
EM: When the CCC did their study and they looked at some of those barriers, they also surveyed pet owners. They found that cost was not actually the biggest barrier to going [to see a specialist]; it was actually they didn’t see the value in going.
And so that goes back to what you said about communicating to the client what the value is in going to a specialist, and how that might be beneficial to their pet. And some of the things that we found in these surveys that we’ve done is that having the client understand what that referral process looks like, or if they’re considering it, having all of the information before they come. The accurate cost estimates tended to be one of the things that clients felt were really important from the specialty side of things.
And when they get to the specialist, how do we make collaboration visible? I think that’s really, really important. I always end all the conversations with, “I’m going to call your primary care vet and let them know what we discussed.” I think making the collaboration visible to the client is really important to make them feel that their patient is at the center of the care team.
Mini Miracles
KB: That says it so well. Many clients who have been the patient themselves can have a really deep sense of how much that means, too, even veterinarians who have been the patient themselves. When you’re on the other side of the table and you’re thinking, “Gosh, I was so scared when I was at that specialist” or “I really appreciated knowing that that specialist talked to my family doctor and they had a conversation about me, where I was important, and they came up with a plan together.” That has happened to me, and I felt so taken care of.
It can be so scary to be sitting there at a specialist’s office and not know the person or the team. And you’re like, “I’m here because something’s wrong.” And with a pet, you can’t explain to them why they’re here, and you’re discussing all these procedures with some stranger. And I really feel that in my heart, where you just look at them and you say, “We’ve got you, we’re all in this together.” That’s just a great, great feeling.
CM: That’s what I would like for everyday veterinary medicine to be. Everybody is on each other’s side.
To learn more about the Collaborative Care Coalition and read their guidelines and white paper, visit collaborativecarecoalition.org. Anyone interested can reach out to CCC’s board members through the contact information on their site. Look for them at local and national conferences speaking about their research and CCC’s mission.
Central Line: The AAHA Podcast is generously sponsored by CareCredit.
Catch the full episode, and every other episode of Central Line: The AAHA Podcast, on major podcast platforms, YouTube, and at aaha.org/podcast.
Elizabeth Maxwell, DVM, MS, DACVS (Small Animal), CVPP, is from Miami, Florida. She earned her veterinary degree from Ross University in 2012, completed a rotating internship at Louisiana State University, and a residency in small animal surgery at the University of Illinois. She then went on to complete a surgical oncology fellowship at the University of Florida and is now a clinical assistant professor in surgical oncology at the University of Florida. She currently serves as president on the board of directors for the Collaborative Care Coalition. |
Candice Manganaro, DVM, completed her bachelor’s degree in science at the University of Central Florida and earned her Doctor of Veterinary Medicine degree from the University of Florida in 2009. As a canine/feline general practitioner in Central Florida, she values client education and stresses the team approach where families and veterinarians work together to care for pets. |
Katie Berlin, DVM, CVA, is the host of Central Line: The AAHA Podcast. |
Photo credits: SDI Productions/E+ via Getty Images, ©AAHA/Kimberly Lamb, Phynart Studio/E+ via Getty Images, urbancow/E+ via Getty Images